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Radiofrequency Facet Denervation

Section: Surgery
Effective Date: July 01, 2018
Revised Date: May 14, 2018

Under sedation and local anesthetic, a needle is directed to the median branch of the dorsal ganglion in the facet joint with fluoroscopic guidance, where multiple thermal lesions are produced by a radio frequency generator.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position

Coverage is subject to the specific terms of the member’s benefit plan.

Radiofrequency Facet Denervation (also known as non-pulsed radiofrequency denervation, facet neurotomy, facet rhizotomy, or articular rhizolysis) of cervical facet joints (C2-C3 thru C7-T1 vertebrae) and lumbar facet joints (T12-L1 thru L5-S1 vertebrae) may be considered medically necessary when ALL of the following criteria are met. No prior spinal fusion surgery in the vertebral level being treated; and

  • Disabling low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical, and radiographic evaluations; and the pain is not radicular; and
  • Pain has failed to respond to three (3) months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; and
  • A successful trial of controlled diagnostic medial branch blocks consisting of two (2) separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in at least a 50% reduction in pain for the duration of the local anesthetic used (e.g., 3 hours longer with bupivacaine than lidocaine) and
  • No therapeutic intra-articular injections (i.e., steroids, saline, or other substances) have been administered for a period of at least 4 weeks prior to the diagnostic medial branch block.

Repeat radiofrequency facet denervation may be considered medically necessary when:

  • The above criteria have been previously met to qualify for an initial treatment; and
  • A minimum time of 6 months has elapsed since prior RF treatment (per side, per anatomical level of the spine).

Radiofrequency facet denervation is considered not medically necessary when the above criteria are not met.

The following procedures are considered experimental/investigational:

  • Radiofrequency denervation for the treatment of chronic spinal/back pain that does not meet the criteria listed above
  • Radiofrequency denervation for the treatment of chronic spinal/back pain when performed at the same anatomic site (side and spinal level) within 6 months of a prior treatment
  • Radiofrequency denervation for the treatment of thoracic or sacroiliac (SI) joint pain
  • Pulsed Radiofrequency
  • Cryodenervation/Cryoablation
  • Laser ablation/laser neurolysis
  • Endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy
  • Paravertebral facet joint nerve destruction with chemical age (chemodenervation/chemical neurolysis) such as alcohol, phenol, hypertonic solutions, or any other miscellaneous agent
  • Therapeutic medial branch blocks Cooled radiofrequency ablation (SInergy).

Procedure Codes

27299 64633 64634 64635 64636 64999 64640
A4649

Place of Service: Outpatient

Radiofrequency Facet Denervation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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