Radiofrequency Facet Nerve Denervation (64622, 64623, 64626, 64627, 64999, and 77003) is a procedure done as a treatment modality for patients with a variety of chronic spinal pain syndromes, including facet joint pain syndrome. This procedure is eligible when performed for any of these indications:

• 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;
• 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;
• A trial of a controlled diagnostic medial branch block under fluoroscopic guidance has resulted in at least a 50% reduction in pain; and
• If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine).

Radiofrequency denervation is considered experimental/investigational for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including, but not limited to, treatment of thoracic facet or sacroiliac (SI) joint pain. The current peer reviewed literature is limited and non-conclusive for indications other than those listed. A participating, preferred, or network provider can bill the member for the denied service.

Pulsed radiofrequency (64999) effectiveness has not yet been established and should be considered experimental/investigational. The current peer reviewed literature is limited and non-conclusive. A participating, preferred, or network provider can bill the member for the denied service.

Description

Radiofrequency facet denervation or radiofrequency ablation (RFA) was introduced as a treatment modality for patients with a variety of chronic spinal pain syndromes, including facet joint pain syndrome. RFA is referred to by numerous terms, including percutaneous nonpulsed radiofrequency facet denervation, thermal radiofrequency, percutaneous facet coagulation, percutaneous radiofrequency neurotomy, radiofrequency facet rhizotomy, and radiofrequency articular rhizolysis. RFA is a pain-reduction technique that may be considered for patients with back pain that is unresponsive to conservative management and for which there is no clear indication for surgery.

Patients generally are sedated for the RFA procedure. Under local anesthetic and with fluoroscopic guidance, a needle is directed to the median branch of the dorsal ganglion in the facet joint, where multiple thermal lesions are produced by a radiofrequency generator. During RFA, an electrode introduced through the skin is used to deliver heat produced by radio waves in order to destroy the sympathetic nerve supply of the painful spinal structure.

Pulsed radiofrequency consists of short bursts of electrical current of high voltage in the radiofrequency range but without heating the tissue enough to cause coagulation. Temperatures do not exceed 42°C at the probe tip versus temperatures in the 60°s C reached in thermal RF denervation, and tissues may cool between pulses. It is postulated that transmission across small unmyelinated nerve fibers is disrupted but not permanently damaged, while large myelinated fibers are not affected.

NOTE:

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.

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.

04/2011, New coverage criteria for radiofrequency facet nerve denervation defined

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Blue Cross and Blue Shield Association. Radiofrequency Facet Nerve Denervation. Medical Policy Reference Manual 7.01.116. Issued June 2010.