Subject:
Radiofrequency Joint Ablation/Denervation
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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CMM-208.1 Definitions
† Radiofrequency joint denervation/ablation (i.e., facet neurotomy, facet rhizotomy) refers to the insertion of a radiofrequency probe towards the medial branch of the posterior primary rami, which supplies the innervation to the facet joints under fluoroscopic guidance. The radiofrequency electrode is then utilized to create a “continuous” heat lesion by coagulating the nerve supplying the joint with the intention of providing pain relief by denervating the painful facet joint. The injection/block applies directly to the facet joint(s) blocked/ablated and not to the number of nerves blocked/ablated that innervate the facet joint(s).
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-208.2 General Guidelines
† The determination of medical necessity for the performance of radiofrequency joint denervations/ablations is always made on a case-by-case basis.
† When performing radiofrequency joint denervations/ablations, it may be necessary to perform the procedure at the same level(s) bilaterally; however, no more than three (3) levels should be performed during the same session/procedure.
† When performing a repeat radiofrequency joint denervation/ablation at the same spinal level(s) as a prior successful denervation/ablation procedure, further diagnostic facet joint injections/medial branch blocks at that spinal level(s) are not necessary.
CMM-208.3 Indications
† A radiofrequency joint denervation/ablation is considered medically necessary for facet mediated pain resulting from disease, injury, or surgery when ALL of the following are met:
® Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation).
® Failure of at least three (3) months of conservative therapy (e.g., exercise, physical methods including physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs [NSAID’s] and/or analgesics) unless contraindicated and the reason(s) for the contraindication(s) is/are documented in the medical record
® Two positive diagnostic facet joint injections/medial branch blocks as evidenced by at least 80% relief of facet mediated pain for at least the expected minimum duration of the effect of the local anesthetic used.
† For an individual with a prior spinal fusion, radiofrequency joint denervation/ablation is considered medically necessary when the above criteria are met and the procedure is performed at an unfused spinal segment located either above or below the fused spinal segment.
† A repeat radiofrequency joint denervation/ablation when BOTH of the following criteria are met:
® There is documented pain relief of at least 50% which has lasted for a minimum of 12 weeks
® The procedure is performed at a minimum of six months following the prior denervation/ablation.
CMM-208.4: Non-Indications
† Performance of a radiofrequency joint denervation/ablation for ANY of the following indications is considered not medically necessary:
® When performed without the use of fluoroscopic guidance
® Performing more than two procedures at the same level(s) during a 12 month period of time
® In the absence of two sequential positive diagnostic facet joint injections/medial branch blocks at the same level(s) for an initial radiofrequency treatment, or for a repeat radiofrequency treatment in the absence of at least 50% relief of facet mediated pain for at least 6 months from a previous radiofrequency treatment at the same level(s).
® When performed for neck pain or low back pain in the presence of an untreated radiculopathy
® When performed at a posteriorly fused spinal motion segment (with the exception of members with clinically suspected pseudarthrosis)
® When performed on more than three (3) contiguous spinal joint levels during the same session/procedure
® When performed to treat pain arising from above C2-3 and below L5-S1 spinal levels
† Performance of radiofrequency joint denervation/ablations for ANY of the following indications is considered investigational:
® Pulsed radiofrequency ablation for chronic pain syndromes
® Endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy
® Cryoablation/cryoneurolysis/cryodenervation
® Chemical ablation (e.g., alcohol, phenol, glycerol)
® Laser ablation
® Ablation by any method for sacroiliac (SI) joint pain
® Cooled radiofrequency ablation
CMM-208.5 Procedure (CPT®) Codes
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| This policy relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. |
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| Code Description/Definition |
| 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) |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of Horizon BCBSNJ and is based on the member’s policy or benefit entitlement structure as well as claims processing rules. |
Medicare Coverage:
There is no National Coverage Determination (NCD) for Radiofrequency Joint Ablation/Denervation. National Coverage Determination (NCD) for Induced Lesions of Nerve Tracts (160.1) notes that payment may be made for these denervation procedures when used in selected cases (concurred in by the Medicare Administrative Contractor’s medical staff) to treat chronic pain. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892), providing coverage for thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves when the LCD criteria is met. Per LCD L34892, non-thermal modalities for facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are considered not reasonable and necessary.
For additional information, refer to Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370
National Coverage Determination (NCD) for Induced Lesions of Nerve Tracts (160.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Radiofrequency Joint Ablation/Denervation
Radiofrequency Facet Joint Denervation for Chronic Back and Neck Pain
Facet Denervation
Facet Rhizotomy
Pulsed Radiofrequency Facet Denervation
Radiofrequency Neurotomy
Rhizotomy, Facet
Cooled Radiofrequency
Thermal Rhizotomy
Endoscopic Dorsal Rhizotomy
Endoscopic Rhizotomy
Sacroiliac Joint Denervation
Sacroiliac Joint Ablation
Sacroiliac Joint Neurotomy
Sacroiliac Joint Rhizotomy
References:
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29. Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy, Spine. 2001;26(13):1411-1416.
30. Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine J. 2017 Nov;17(11):1770-1780.
31. Lord S, Barnsley L, Wallis B, McDonald G, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996; 335:1721-1726.
32. Maas ET, Ostelo RW, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, van Tulder MW. Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev. 2015 Oct 23;(10):CD008572. doi: 10.1002/14651858.CD008572.pub2.
33. MacVicar J, Borowczyk JM, MacVicar AM, Loughnan BM, Bogduk N. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med. 2012;13:647-654.
34. MacVicar J, Kreiner DS, Duszynski B, Kennedy DJ. Appropriate use criteria for fluoroscopically guided diagnostic and therapeutic sacroiliac interventions: results from the spine intervention society convened multispecialty collaborative. Pain Med. 2017;18(11):2081-2095.
35. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician. 2013;16:S49-S283.
36. Manchikanti L, Kaye AD, Boswell MV, et al. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician. 2015;18:E535-E582.
37. Manchikanti L, Cash K, Pampati V, Fellows B. Influence of psychological variables on the diagnosis of facet joint involvement in chronic spinal pain. Pain Physician. 2008 ;11(2):145-160.
38. Manchikanti L, Manchukonda R, Pampati V, et al. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007;88(4):449-455.
39. Manchikanti L, Staats P, Singh V, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Phys. 2003;6:3-81.
40. Manchukonda R, Manchikanti K, Cash K, et al. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007;20(7):539-545.
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47. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Medicine. 2012;13:383-398.
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49. Sapir DA, Gorup JM. Radiofrequency medial branch neurotomy in litigant and non-litigant
patients with cervical whiplash. Spine (Phila Pa 1976). 2001;26:E268-E273.
50. Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine. 2004;29(21):2471-2473.
51. Slipman C, Bhat A, Gilchrist R, et al. A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain, Spine J. 2003;3(4):310-316.
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54. Tzaan W, Tasker R. Percutaneous radiofrequency facet rhizotomy--experience with 118 procedures and reappraisal of its value. Canadian Journal of Neurological Sciences. 2000;27(2):125-130.
55. Vallejo R, Benyamin R, Kramer J, et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. 2006;7(5):429-434.
56. van Kleef M, Barendse G, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine. 1999;24(18):1937-1942.
57. van Wijk R, Geurts J, Wynne H, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain. 2005; 21(4):335-344.
58. Van Zundert J, Patihn J, Kessels A, et al. Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double-blind sham controlled randomized clinical trial. Pain. 2007;127:173-182
59. Washington State Department of Labor and Industries. Guideline on diagnostic facet medial nerve branch blocks and facet neurotomy. Provider Bull. 2005;(PB 05-11):1-6.
60. Workloss Data Institute. Official Disability Guidelines 2008.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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