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Coverage criteria policies

Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck and back pain

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Radiofrequency ablative denervation procedures of the spine require prior authorization.

Diagnostic medial branch block (MBB) does not require prior authorization, but is subject to quantity coverage limits (see “Coverage” section)

Outside the scope of this policy:

  • Intra-articular injections of the paravertebral facet (zygapophyseal) joint
  • Radiculopathic limb pain
  • Pain from spinal instability, fracture, malignancy, or spinal stenosis
  • Diagnostic provocative discography or intradiscal injection
  • Discectomy procedures, either percutaneous or open
  • Implanted devices or pumps
  • Vertebroplasty or kyphoplasty
  • Chemonucleolysis

Coverage

Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck and back pain are generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

Initial Radiofrequency ablative denervation (RFA) is covered when the following criteria are met:

  1. RFA is covered to treat axial (non-radicular) neck and low back pain if all of the following criteria are met:
    1. Severe pain limiting activities of daily living for at least 3 months despite conservative treatments (structured exercise, physical therapy, activity modification, pharmacological management), - these must be documented on the request for prior authorization;
      Conservative therapy
      must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
      Formal physical therapy
      , at least four visits over a six week course, including active muscle conditioning is required, or there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.
      and
    2. Skeletal and neuro imaging studies confirm that the principal cause of the pain is not disc herniation, spinal instability, fracture, malignancy, or spinal stenosis; and
    3. Within 6 months prior to the procedure, two trials of diagnostic medial branch block injections must be received as described below:,
      1. The first trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain (provider must include with the request the pre-injection pain score and post-injection pain score as reported by the patient); and
      2. There has been elapsed time interval of at least 2 weeks and not more than 6 months between the first trial nerve block injections and the second trial nerve block injection; and
      3. The second trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain (provider must include with the request the pre-injection pain score and post-injection pain score as reported by the patient); and
      4. The first and second injections were performed under fluoroscopic guidance, with archived images saved in two projections.
        *note: Intra-articular injections of the paravertebral facet (zygapophyseal) joint are not considered diagnostic for the purposes of assessing suitability for RFA
  2. RFA treatment procedure is limited to 3 levels per side in a 6 month period (prior authorization form requires identification of the level and side). Three levels is defined as three (3) punctures (innervates two facet joints), each of which lesions one medial branch of the dorsal ramus nerve; (Example: one unit of 64622 plus two units of 64623 equals three levels), or for a bilateral procedure, three pairs of punctures. (For bilateral RFA’s, the modifier 50 should be used.)
  3. Repeat Radiofrequency ablative denervation (RFA) at the same level is covered when the following criteria are met:
    1. A minimum of six months has elapsed since the initial RFA; and
    2. The initial RFA relieved at least 50% of the pain within 3 months of the procedure date as reported by the patient; and
    3. Severe pain limiting activities of daily living for at least 3 months despite conservative treatments (structured exercise, physical therapy, activity modification, pharmacological management), - these must be documented on the request for prior authorization;

      Conservative therapy must include physical therapy (PT) and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).

      Formal physical therapy, at least four visits over a six week course, including active muscle conditioning is required, or there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to initiate or complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted

Indications that are not covered

The following Radiofrequency Ablation (RFA) procedures are considered investigational and not covered:

  1. Sacroiliac joint Radiofrequency Ablation (RFA) - Please refer to the related content for the link to sacroiliac joint pain treatment procedures policy
  2. Pulsed Radiofrequency Ablation (RFA) (64999)
  3. Cooled Radiofrequency Ablation (RFA)
  4. Laser denervation procedures
  5. Thoracic facet radiofrequency ablation

Definitions

Radiofrequency ablative denervation (also known as facet neurotomy, facet rhizotomy, or articular rhizolysis) - an invasive procedure in which radiofrequency energy is applied via a percutaneous probe in order to irreversibly destroy the medial branch of the dorsal ramus that supplies a facet (zygapophysial) joint.

Diagnostic medial branch block (MBB) - an invasive procedure in which a local anesthetic drug (e.g. lidocaine), with or without concomitant corticosteroid, is injected in close proximity to the medial branch of the dorsal ramus that supplies a facet (zygapophysial) joint. The intent is to provide temporary relief of pain and serve as a diagnostic test to localize facetogenic pain, so as to guide possible future radiofrequency denervation. The injection is NOT intra-articular (into the joint).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Radiofrequency Ablation Codes that require prior authorization:

Codes

Description

64633

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

64634

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64635

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

64636

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

64640

Destruction by neurolytic agent; other peripheral nerve or branch

64999

 
Diagnostic medial branch block (MBB) codes:

Codes

Description

64490

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

64491

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

64492

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

64493

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

64494

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

64495

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

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Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Chou, R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on January, 2018.)
  2. Cohen, S. P., Williams, K. A., Kurihara, C., Nguyen, C., Shields, C., Kim, P., … Strassels, S. A. (2010). Multicenter, Randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic Medial branch (facet joint nerve) block treatment paradigms before lumbar facet Radiofrequency Denervation. Anesthesiology, 113(2), 395–405.
  3. Cohen, S. P., Strassels, S. A., Kurihara, C., Crooks, M. T., Erdek, M. A., Forsythe, A., & Marcuson, M. (2009). Outcome predictors for Sacroiliac joint (lateral branch) Radiofrequency Denervation. Regional Anesthesia and Pain Medicine, 34(3), 206–214.
  4. ECRI Institute. Cooled Radiofrequency Nerve Ablation for Treating Sacroiliac Joint Pain. Plymouth Meeting (PA): ECRI Institute; 2014 Oct 28. (Custom Rapid Review).
  5. ECRI Institute. (2012). Radiofrequency Denervation for treating chronic low-back pain. Plymouth Meeting, PA: ECRI Institute.
  6. ​ECRI Institute. Radiofrequency Denervation for Treating Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2015 Dec 28. (Custom Rapid Review).
  7. Hayes, Inc. Hayes Clinical Research Response. Coolief Cooled RF (Halyard Health) for Knee and Hip Pain. Lansdale, PA: Hayes, Inc.; May, 2016.
  8. Hayes, Inc. Hayes Technology Brief. Cooled Radiofrequency Denervation of the Sacroiliac Joint (Pain Management SInergy System, Baylis Medical Co. Inc.) for Treatment of Chronic Low Back Pain. August, 2011, Archived August 2012.
  9. Hayes, Inc. Hayes Medical Technology Directory Report. Percutaneous Radiofrequency Ablation for Cervical and Thoracic Spinal Indications. Lansdale, PA: Hayes, Inc.; November, 2016, Reviewed November, 2017
  10. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Facet Joint Denervation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; December, 2016, Reviewed November, 2017
  11. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; May, 2007. Reviewed July, 2011. Archived, April, 2012.
  12. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency ablation for sacroiliac joint pain. Lansdale, PA: Hayes, Inc.; August, 2012. Reviewed May, 2016.
  13. Helm S, Hayek SM, Benyamin RM, Manchikanti L. (2009) Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician. Jan-Feb;12(1):207-32
  14. Kapural L, Ng A, Dalton J, Mascha E, Kapural M, de la Garza M, Mekhail N. (2008). Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med Jan-Feb 9 60-7.
  15. Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R. M., Boswell, M. V., Buenaventura, R. M., ... Hirsch, J. A. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician, 16(2 Suppl).
  16. Manchikanti KN, Atluri S, Singh V, Geffert S, Sehgal N, Falco FJ. An update of evaluation of therapeutic thoracic facet joint interventions. (2012). Pain Physician 15(4): E463-E481.
  17. Washington State Health Care Authority. Health Technology Assessment. Facet Neurotomy May 2014.

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Policy activity

  • 03/14/2005 - Date of origin
  • 05/01/2017 - Effective date
Review date
  • 01/2018
Revision date
  • 01/06/2017

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