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Medical Policy: 07.01.10
Original Effective Date: July 2002
Reviewed: May 2011
Revised: April 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Facet joints, which provide both mobility and stability for the spinal column, have joint capsules that are richly supplied by a branch of the posterior ramus of the spinal nerve. Thus, it is possible for the facet joints to contribute to the sensation of neck and back pain and therefore, selective denervation by radiofrequency has been used successfully as a treatment option.
Percutaneous radiofrequency facet denervation, also known as radiofrequency facet joint rhizotomy or facet neurotomy is performed with the patient lying on a fluoroscopy table. The procedure can be done with the patient under intravenous conscious sedation. For each target nerve a spinal needle is introduced to guide the placement of the radiofrequency electrode, which is advanced to the desired level. The targeted nerve is coagulated by raising the tissue temperature with radiofrequency energy, and the tip of the electrode monitors the temperature of the tissue.
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Prior Approval:
Prior approval is recommended. Submit a prior approval now.
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Policy:
Percutaneous radiofrequency facet joint rhizotomy may be considered medically necessary when all of the criteria listed below are met:
- Patient is diagnosed with spinal or myofascial or non-radicular pain syndrome of the cervical or lumbar area
- Other causes of generalized back pain are ruled out
- Recurrent pain with a positive response to local anesthetic block is documented
- Pain persists for at least 6 months; and
- Failed conservative multimodality therapies over 6 months in the last year.
Radiofrequency denervation performed to the medial branch nerves for a maximum of three facet levels, or denervation of five spinal medial branches unilaterally will be allowed on a single visit.
Since pain relief may be transient from this procedure, it may be repeated 6 months after the initial treatment.
Percutaneous radiofrequency facet joint rhizotomy is considered investigational for all uses that do not meet the criteria listed above, including but not limited to the treatment of thoracic facet joint pain.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 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)
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Selected References:
- A review of the medical literature and recommendations from Wellmark’s Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- Tzaan W-C, Taskere RR. Percutaneous radiofrequency facet rhizotomy-experience with 118 procedures and reappraisal of its value. Canadian Journal of Neurological Sciences2002;27:125-130.
- Manchikanti L. Facet joint pain and the role of neural blockade in its management. Current Review of Pain 1999;3:348-358.
- Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000;25:1270-1277.
- McDonald GJ, Lord SM, Bogduk N. Long-term follow-up of patients treated with cervical radiofrequency neurotomy of chronic neck pain. Neurosurgery1999;45(1):61-68.
- Van Kleef et al. Randomized trial of RF lumber facet denervation for chronic low back pain. Spine 1999;24(18):1937-1942.
- Lord SM, Barnsley L, Wallis BJ et al. RF neurotomy in chronic ZA pain. New England Journal of Medicine 1996.
- Gallagher J. et al. RF facet joint denervation in treatment of LBP: Prospective controlled double blind study. Pain Clinic 1994’7:193-198.
- Ban Wijk, de al. Proven efficacy of RF for cervical and lumber ZA pain. 2001
- Pevsner Y, Shabat S, Catz A, Folman Y, Gepstein R.: The role of radiofrequency in the treatment of mechanical pain of spinal origin. Eur Spine J. 2003 Oct 28 [Epub ahead of print].
- ECRI. Radiofrequency Neuroablation for Low Back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 May 19. 13p. (ECRI Hotline Response). Also available: http://www.ecri.org.
- Boswell MV et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007 Jan;10(1):7-111.
- ECRI Institute. Radiofrequency Neuroablation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2009 Sept 30. 12 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- ECRI Institute. Radiofrequency Neuroablation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2010 Jul 2111 p. [ECRI hotline response]. Also available: http://www.ecri.org
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Policy History:
Date Reason Action
May 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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