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Radiofrequency ablative (RFA) denervation procedures for chronic facet-mediated neck & back pain - Retire 5/1/2014

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 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:

  • Sacroiliac joint (SIJ) Radiofrequency Ablation (RFA) – please see related content at right for link to sacroiliac joint pain treatment procedures 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

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 with the following criteria are met:

  1. RFA is covered to treat axial (non-radicular) neck and 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, 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. Documentation of formal physical therapy would be the therapist’s notes. 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. FIRST Trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain (provider must include with the request the preinjection pain score and postinjection pain score as reported by the patient); AND
      2. 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. SECOND Trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain (provider must include with the request the preinjection pain score and postinjection pain score as reported by the patient); AND
      4. 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 is limited to 3 levels per treatment procedure and only 1 RFA treatment procedure per level per side in a 6 month period (prior authorization form will ask for the level and side).
    1. 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.)
    2. OR for a bilateral procedure, three pairs of punctures. (For bilateral RFA’s, the modifier 50 should be used.)

Repeat Radiofrequency ablative denervation (RFA) at the same level is covered when the following criteria are met:

  1. At least six months has elapsed since the initial RFA; AND
  2. One diagnostic medial branch block injection performed under fluoroscopic guidance is required; AND
  3. The diagnostic medial branch block (MBB) injection in # 2 above relieves at least 70% of the pain (provider must include with the request the preinjection pain score and postinjection pain score as reported by the patient).

Indications that are not covered

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

  1. Sacroiliac joint Radiofrequency Ablation (RFA)
  2. Pulsed Radiofrequency Ablation (RFA)
  3. Cooled Radiofrequency Ablation (RFA)
  4. Laser denervation procedures

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) is 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:

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)

Diagnostic medial branch block (MBB) codes:

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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Bibliography

Bibliography available upon request.

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.