Medical Policy: 07.01.58
Original Effective Date: July 2002
Reviewed: June 2015
Revised: June 2015
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.
A variety of terms may be used to describe percutaneous radiofrequency denervation including radiofrequency ablation (RFA), non-pulsed radiofrequency, radiofrequency neuroablation, radiofrequency lesioning, radiofrequency neurotomy, radiofrequency facet rhizotomy and radiofrequency articular rhizolysis.
Percutaneous radiofrequency facet joint denervation is used to treat neck or back pain originating in the facet joints with degenerative changes. Diagnosis of facet joint pain is difficult and typically is confirmed by a positive response from nerve blocks. The goal of facet joint denervation is long-term pain relief. However, the nerve(s) regenerate, and repeat procedures may be required.
The facet joints, also known as apophyseal or zygapophyseal joints, are formed by the superior and inferior articular processes of sequential vertebrae. The nerves that communicate with these joints sometimes become inflamed or impinged, which leads to pain.
Prior to having a percutaneous facet joint denervation procedure, a diagnostic paravertebral facet joint nerve block is commonly performed to assess the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome. A diagnostic nerve block localizes the nerve(s) responsible for the pain or neuromuscular dysfunction, particularly when multiple sources of pain are potentially present. This procedure is performed under fluoroscopic guidance to ensure accurate placement of the needle in the facet joint.
Upon needle placement, a long acting local anesthetic is injected to temporarily numb the facet joint. The individual is asked to engage in the activities that had previously precipitated pain, and to evaluate the effect of the procedure at 4 to 8 hours post injection. A temporary or prolonged absence of spinal pain strongly suggest that the facet joint is the source of the symptoms. A repeat injection may be needed to establish consistency of results, particularly if diagnostic nerve blocks are followed by neurolysis.
Radiofrequency facet joint denervation is performed under local anesthetic with fluoroscopic guidance. A percutaneously introduced electrode applies heat from radio waves to selectively destroy sensory afferent nerve fibers, thereby interrupting pain signals from a specific site. A minimum of two levels must be addressed to denervate a single joint. Radiofreqency (RF) denvervation is directed at each of the levels to be lesioned. Destruction of the nerve may be permanent or temporary. In some cases, the treated nerve repairs itself and becomes less irritable, thus resulting in continued resolution of the pain. In cases where the pain returns, the procedure can be repeated in the same joint, following an elapsed time of at least 6 months and a previously positive result from RF denervation, as measured by more than 50% pain relief and associated functional improvement.
Based on the medical literature data indicates that in carefully selected individuals with cervical (C2 thru C7) and lumbar or lumbosacral (L1 thru L5-S1) facet joint pain, percutaneous radiofrequency facet joint denervation can result in improved outcomes.
The literature on thoracic radiofrequency facet joint denervation and radiofrequency denervation of the sacroiliac joint is limited, there is insufficient evidence regarding the safety and effectiveness of radiofrequency denervation and therefore is considered investigational.
There is insufficient evidence to evaluate the efficacy of other methods of denervation (e.g. alcohol, laser, cryodenervation) for facet joint pain and therefore, these techniques are considered investigational.
Practice Guidelines and Position Statements
The American Society of Interventional Pain Physicians (ASIPP)
Update of Comprehensive Evidence Based Guidelines for Interventional Techniques in Chronic Spinal Pain. 2013 Guidance and Recommendations:
Management of Neck Pain
Therapeutic Cervical Facet Joint Interventions
- The evidence is fair for cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intra-articular injections.
- Conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks are recommended in managing chronic neck pain afrer the appropriate diagnosis from controlled diagnostic blocks.
Management of Low Back Pain
Therapeutic Lumbar Facet Joint Interventions:
- The evidence for lumbar conventional radiofrequency neurotomy is good; limited for pulsed radiofrequency neurotomy; fair to good for lumbar facet joint nerve blocks, and limited for intra-articular blocks.
Therapeutic Sacroiliac Joint Interventions
- The evidence is limited for both pulsed radiofrequency and conventional radiofrequency neurotomy
Management of Thoracic Pain
- Radiofrequency neurotomy and conventional radiofrequency neurotomy may be performed on emerging evidence.
A number of radiofrequency generators and probes have been cleared for marketing through the U.S. Food and Drug Administration’s (FDA) 510(k) process. One device, the Sinergy by Kimberly Clark/Baylis, is a water cooled single use probe that received FDA clearance in 2005, listing the Baylis Pain Management Probe as a predicate device. The intended use is in conjunction with a radiofrequency generator to create radiofrequency lesions in nervous tissue.
Prior approval is required.
See Related Medical Policies
Radiofrequency facet joint denervation is considered investigational for the treatment of chronic spinal/back pain for all uses that do not meet the medical necessity criteria related to cervical (C2 thru C7) and lumbar facet (L1 thru L5-S1) joint pain because there is insufficient evidence in the published medical literature to demonstrate the safety and efficacy.
Radiofrequency denervation is considered investigational for the treatment of thoracic facet joint pain or sacroiliac joint pain.
Based on the peer reviewed medical literature there is insufficient evidence to demonstrate the safety and efficacy of radiofrequency facet joint denervation for the treatment of thoracic facet joint pain or for sacroiliac joint pain and therefore, radiofrequency facet joint denervation is considered investigational.
All other methods of denervation is considered investigational for the treatment of chronic spinal/back pain, including but not limited to laser denervation, chemodenervation (e.g. alcohol, phenol, or high concentrations local anesthetics) and cryodenervation.
Based on the peer reviewed medical literature there is insufficient evidence to evaluate the safety and effectiveness of these other methods of denervation and therefore, these techniques are considered investigational.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
- 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
- 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
- American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
- Chua NH, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanism and potential indications-a review. Acta Neurochir. 2011 Apr;153(4):763-71.
- 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.
- ECRI Institute. Radiofrequency Denervation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2011 August 8. [Hotline Response]. Also available at: http://www.ecri.org.
- ECRI Institute; 2012 October, Hotline Response, Radiofrequency Denervation for Treating Chronic Low Back Pain. Also available at http://www.ecri.org
- American Society of Interventional Pain Physicians (ASIPP). 2013 Practice Guidelines for Chronic Spinal Pain.
- Manchikanti L, Abdi S, Atluri S et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician 2013; 16(2 Suppl):S49-283
- UpToDate® Website. Subacute and chronic low back pain: nonsurgical interventional treatment. September 2013. Available at: https://www.uptodate.com/home/index.html
- Chou Roger M.D., Loeser John D, M.D., et. al., Interventional Therapies, Surgery and Interdisciplinary Rehabilitation for Low Back Pain an Evidence Based Clinical Practice Guideline from the American Pain Society. Spine Volume 34, Number 10, pp 1066-1077
- National Guideline Clearinghouse Cervical and Thoracic Spine Disorders, American College of Occupational and Environmental Medicine (ACOEM); 2011 p. 1-332
- MedScape. Radiofrequency Treatment in Chronic Pain. Also available at www.medscape.com/viewarticle/718292
- Gupta Anita D.O., PharmD, Evidence Based Review of Radiofrequency Ablation Techniques for Chronic Sacral Iliac Joint Pain, PainMedicine News June 2010
- UpToDate. Treatment of Neck Pain, Zacharia Isaac, M.D., Topic last updated March 16, 2015. Also available at www.uptodate.com
- UpToDate. Subacute and Chronic Low Back Pain: Nonsurgical Interventional Treatment, Roger Chou, M.D., Topic last updated May 13, 2014. Also available at www.uptodate.com
Date Reason Action
May 2011 Annual review Renew policy
April 2012 Annual review Renew policy
Policy was retired September 1, 2012
September 2013 New policy
July 2014 Annual review Renew policy
June 2015 Annual review Policy revised
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 © 2012 American Medical Association. All Rights Reserved.