Medical Policy: 07.01.58 

Original Effective Date: July 2002 

Reviewed: August 2017 

Revised: August 2017 

 

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:

Most back pain resolves with conservative treatment, but a significant number of individuals may develop chronic spinal pain. Facet joint pain has been attributed to chronic spinal pain and radiofrequency denervation or ablation of the facet joint(s) has been proposed and used with increased frequency to treat neck, upper and lower back pain and sacroiliac joint pain.

 

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.

 

The facet joints, also known as apophyseal or zygapophyseal joints, are formed by the superior and inferior articular processes of sequential vertebrae. The facet joints are joints in the spine that make the back flexible and enable an individual to bend and twist. Nerves exit the spinal cord through these joints on their way to other parts of the body. Healthy facet joints have cartilage, which allows the vertebrae to move smoothly against each other without grinding.  The nerves that communicate with these joints sometimes become inflamed or impinged, which leads to facet joint pain.

   

Percutaneous radiofrequency facet joint ablation/denervation is used to treat neck or back pain originating in the facet joints with degenerative changes and for the treatment of sacroiliac joint pain. The diagnosis of facet joint pain is confirmed by a positive response from at least two diagnostic blocks i.e. facet joint injections or medial branch blocks. The goal of facet joint denervation is long-term pain relief. However, the nerve(s) may regenerate, and repeat procedures may be required.

 

Radiofrequency facet joint ablation/denervation is performed under local anesthetic with fluoroscopic guidance. A percutaneously introduced electrode applies heat (80 to 85 degrees Celsius) 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 ablate/denervate a single joint. Radiofrequency ablation (RFA)/denervation is directed at each of the levels to be lesioned. Destruction of the nerve may be permanent or temporary. In cases where the pain returns, the procedure can be repeated in the same joint(s) or spinal levels.

 

Thoracic Facet Joint Pain

Thoracic pain is less common than either low back pain (lumbar pain) or neck pain (cervical pain), however, the degree of disability resulting from thoracic pain disorders may be similar to that of low back pain (lumbar pain) and neck pain (cervical pain). Investigations into the assessment of various causes of thoracic pain and the management of thoracic pain are less frequent. Thoracic facet joints have been shown to be a pain generator of mid and upper back pain and radiofrequency ablation/denervation has been used in managing thoracic facet joint pain.

 

Conventional clinical and radiologic techniques are unreliable in diagnosing thoracic facet joint pain. Controlled local anesthetic blocks of thoracic facet joints or medial branch blocks are recommended to diagnosis facet joint pain. The criterion standard for a positive response is 75% pain relief. Radiofrequency ablation/denervation has been used to manage pain of thoracic facet joint(s), using thermal lesioning at 80 to 85 degrees Celsius. The mechanism of radiofrequency ablation/denervation is by denaturing of the nerves. Pain may return when the nerves regenerate requiring repeat procedures. Systematic reviews assessing radiofrequency ablation/denervation for the treatment of thoracic facet joint pain showed limited evidence.

 

Based on the review of the peer reviewed medical literature there is limited evidence regarding radiofrequency ablation/denervation of the thoracic facet joint(s) for chronic pain, the literature includes observational studies and systemic reviews. There is insufficient evidence of high quality data evaluating the safety and effectiveness of treatment with radiofrequency ablation/denervation of the thoracic facet joint(s) for chronic pain.  Additional well designed comparative studies are needed to determine the effects of this technology on net health outcomes.  Also, the 2013 evidence based guideline by American Society of Interventional Pain Physicians (ASIPP) recommendations states the evidence for radiofrequency neurotomy (denervation/ablation) is limited.  Therefore, radiofrequency ablation/denervation for thoracic facet joint(s) is considered investigational.

 

Sacroiliac Joint Pain

Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back and/or buttock pain with or without lower extremity pain.  Radiofrequency ablation/denervation has been used to manage sacroiliac joint pain.

 

The sacroiliac joint receives innervation from the lumbosacral nerve roots. There is no universally accepted gold standard for the diagnosis of low back pain stemming from sacroiliac joints. In systematic review evaluating a battery of tests to identify the disc, sacroiliac joint, or fact joint as the source of low back pain, the review suggested that a combination of sacroiliac joint pain maneuvers (distraction, thigh thrust, FABER (flexion, abduction, external rotation), compression, Gaenslen’s (applies torsional stress on SI joints)), appears to be useful in pinpointing the sacroiliac joint as the principle source of symptoms in patients with pain below the fifth lumbar vertebra. This review also concluded that although a positive bone scan has high specificity, it is associated with a very low sensitivity, which means that the majority of patients with sacroiliac joint pain will not be accurately identified. 

 

Due to the inability to make the diagnosis of sacroiliac joint pain with non-invasive tests, sacroiliac joint blocks appear to be the evaluation of choice to provide appropriate diagnosis. A positive response is considered ≥ 75% relief or with ability to perform previous painful movements. Radiofrequency ablation/denervation has been used to manage pain of the sacroiliac joint, using thermal lesioning at 80 to 85 degrees Celsius.  The mechanism of radiofrequency ablation/denervation is by denaturing of the nerves. Pain may return when the nerves regenerate requiring repeat procedures. Systematic reviews assessing radiofrequency ablation/denervation for the treatment of sacroiliac joint pain showed limited evidence.

 

Based on review of the peer reviewed medical literature, the literature on radiofrequency ablation/denervation of the sacroiliac joint is limited to small randomized controlled trials, observational studies and systematic reviews. There are small randomized controlled trials (RCTs) that report short term benefit, but these are insufficient to determine the overall effect on net health outcomes. Further high quality controlled trials are needed that compare this procedure in defined populations with placebo and with alternative treatments. Also, the 2013 evidence based guideline by American Society of Interventional Pain Physicians (ASIPP) recommendations states the evidence for radiofrequency neurotomy (denervation/ablation) is limited.  The current evidence on sacroiliac joint radiofrequency ablation/denervation is insufficient to permit conclusions regarding the effect of this procedure on net health outcomes and therefore is considered investigational for the treatment of sacroiliac joint pain.  

 

Alternative Methods of Ablation/Denervation in the Treatment of Facet Joint Pain and Sacroiliac Joint Pain

Alternative methods of ablation/denervation in the treatment of facet joint pain and sacroiliac joint pain include but are not limited to the following: laser denervation, chemical neurolysis (chemodenervation) (e.g. alcohol, phenol, glycerol or hypertonic saline), cryodenervation (cryoablation), cooled radiofrequency denervation/ablation, and pulsed radiofrequency ablation.  

 

Laser Denervation

Laser denervation involves the use of a laser to denervate or destroy the nerves related to facet joint pain. In 2007, Iwatsuki et. al. reported laser denervation to the dorsal surface of the facet capsule in 21 patients who had a positive response to a diagnostic medial branch block. One year after laser denervation, 17 patients (81%) experienced greater than 70% pain reduction. In 4 patients (19%) who had previously undergone spinal surgery, the response to laser denervation was not successful. There also was no control group in this study. Additional controlled trials are needed to evaluate this technique. There is insufficient evidence to support the safety and efficacy of laser denervation for facet joint pain or sacroiliac joint pain.    

 

Chemical Facet Neurolysis/Facet Chemodenervation

Chemical facet neurolysis also referred to as chemical ablation, chemodenervation or chemical denervation involves an injection of neurolytic agent(s) such as phenol, alcohol, glycerol or hypertonic saline to denervate a nerve. The use of chemical neurolysis (chemodenervation) has been proposed as an option for facet joint and sacroiliac joint pain relief. The chemical ablating agent is injected into the facet joint nerve or sacroiliac joint. However, there is lack of published data to support the safety and efficacy of this technique.  

 

Cryodenervation (Cryoablation

Cryodenervation (cryoablation) involves inserting a slim, laminated, double-walled cryodenervation probe under local anesthesia. The cryodenervation probe has been cooled to -70 degrees Celsius by carbon dioxide, thereby freezing the pain causing nerves. However, there is lack of published data to support the safety and efficacy of this technique for the treatment of facet joint pain and sacroiliac joint pain.   

 

Cooled Radiofrequency Denervation

Cooled radiofrequency denervation is a newer technology that allows for higher power delivery and larger volume of treated tissues with decreased risk of adjacent tissue damage. Cooled radiofrequency (also referred to as cooled radiofrequency ablation or cooled radiofrequency neurotomy) uses a water-cooled radiofrequency probe to ablate a larger lesion size and treat a larger area than standard radiofrequency technology. Procedures utilizing this alternate treatment include sacroiliac joint denervation and denervation of the facet joints.

 

Once such cooled radiofrequency denervation/ablation procedure is called COOLIEF which is a non-surgical pain relief option for those suffering from chronic back pain.  This procedure uses cooled radiofrequency energy to target the sensory nerves causing pain. Radiofrequency (RF) energy heats and cools tissue at the site of pain. COOLIEF circulates water through the area that is larger than conventional RF treatments. This combination targets the pain-causing nerves without excessive heating, leading to pain relief. The patient should feel pain relief within one to two weeks. In some patients, the pain relief can be relatively long lasting and in others additional treatments may be required. 

  • COOLIEF Cervical Cooled Radiofrequency
  • COOLIEF Lumbar Cooled Radiofrequency
  • COOLIEF Thoracic Cooled Radiofrequency
  • COOLIEF Sinergy Sacroiliac Cooled Radiofrequency

Based on review of the peer reviewed medical literature there is a limited number of studies regarding the use of cooled radiofrequency denervation/ablation for sacroiliac joint pain and cervical, thoracic and lumbar facet joint pain. The limited data regarding the use of cooled radiofrequency denervation/ablation of sacroiliac joint pain suggests some patients may obtain short term relief from the use of ablative treatment along with the reduction of pain, however, the long term efficacy remains unknown. Limitations also include no comparison with conventional radiofrequency treatment for sacroiliac joint pain. Currently there are ongoing studies evaluating the use of cooled radiofrequency ablation for the treatment of chronic thoracic and lumbar back pain. Additional long term comparative controlled studies are needed. The evidence is insufficient to establish the safety and efficacy of cooled radiofrequency denervation /ablation for the treatment of facet joint pain and sacroiliac joint pain.

 

Pulsed Radiofrequency

Pulsed radiofrequency (PRF) ablation has been proposed as a possibly safer alternative to non-pulsed or continuous radiofrequency ablation (RFA) in the treatment of a variety pain syndromes. Pulsed radiofrequency uses short bursts of radiofrequency current (heat is dissipated during the silent period), rather than the continuous current, which allows the needle to remain relatively cool so that the tissue cools slightly between each burst, reducing the risk of destroying nearby tissue. Pulsed radiofrequency causes the transmission across small unmyelinated nerve fibers to be disrupted, but not permanently damaged. This is because the temperature will not exceed 42 degrees Celsius, versus 80 degrees Celsius reached in non-pulsed or continuous radiofrequency ablation (RFA).

 

Summary of Evidence

Based on review of the peer reviewed medical literature there is insufficient evidence regarding the use of laser denervation, chemical neurolysis (chemodenervation), cryodenervation (cyroablation), cooled radiofrequency denervation/ablation (including but not limited COOLIEF radiofrequency) and pulsed radiofrequency ablation for the treatment of the facet joint pain and sacroiliac joint pain. Long term controlled studies are lacking. Additional randomized controlled clinical trials with larger patient populations and with longer follow up are needed. The evidence is insufficient to demonstrate the safety and long term efficacy to support the use of these techniques in the treatment of facet joint pain and sacroiliac joint pain.

 

Practice Guidelines and Position Statements

American Society of Anesthesiologists Task Force and American Society of Regional Anesthesia and Pain Medicine

In 2010, the American Society of Anesthesiologists Task Force and American Society of Regional Anesthesia and Pain Medicine issued a practice guidelines for chronic pain management which included the following:

 

Ablative techniques include chemical denervation, cryoneurolysis or cryoablation, thermal intradiscal procedures (i.e. intervertebral disc annuloplasty (IDET), transdiscal bioaculopathy), and radiofrequency ablation.  

 

Recommendations for Ablative Techniques:

  • Chemical denervation: (e.g. alcohol, phenol or high concentration local anesthetic) should not be used in the routine care of patients with chronic non-cancer pain.
  • Cryoablation: may be used in the care of selected patients (e.g. post-thoracotomy pain syndrome, low back pain (medial branch), and peripheral nerve pain)
  • Radiofrequency ablation: conventional (e.g. 80 degrees Celsius) or thermal (e.g. 67 degrees Celsius) radiofrequency ablation of the medical branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have temporary relief. Conventional radiofrequency ablation may be performed for neck pain, and water cooled radiofrequency ablation may be used for chronic sacroiliac joint pain. Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of radicular pain.       

Guideline does not address or indicate the use of radiofrequency ablation for thoracic facet joint pain and for sacroiliac joint pain.

 

The American Society of Interventional Pain Physicians (ASIPP)

In 2013, the American Society of Interventional Pain Physicians (ASIIP) updated their evidence based guidelines for interventional techniques in chronic spinal pain which included the following recommendations:

 

Lumbar Spine (Includes Sacroiliac Joint Pain):
  • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intra-articular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy.

Systematic reviews assessing radiofrequency neurotomy for sacroiliac joint pain showed limited evidence.

 

Thoracic Spine
  • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks.
  • The evidence is fair for thoracic epidural injections in managing thoracic pain.
  • The evidence for therapeutic facet joint nerve blocks is fair; limited for radiofrequency neurotomy; and not available for thoracic intra-articular  injections.

Based on 2 observational studies meeting methodological quality assessment criteria, the evidence for thoracic radiofrequency neurotomy is limited, but emerging.

 

Regulatory Status

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.  

 

Prior Approval:

 

Prior approval is required.

 

Policy:

See Related Medical Policies

  • Pulsed Radiofrequency  07.01.41

  • Ablative Treatments for Occipital Neuralgia and Headaches*  07.01.66

  • Radiofrequency Ablation of Peripheral Nerves to Treat Chronic Knee Pain and Plantar Fasciitis*  07.01.73 

Radiofrequency Ablation (RFA)/Denervation of Thoracic Facet Joint(s)

Radiofrequency ablation (RFA/denervation is considered investigational for the treatment of thoracic facet joint pain.

 

Based on the review of the peer reviewed medical literature there is limited evidence regarding radiofrequency ablation (RFA)/denervation of the thoracic facet joint(s) for chronic pain, the literature includes observational studies and systemic reviews. There is insufficient evidence of high quality data evaluating the safety and effectiveness of treatment with radiofrequency denervation/ablation in the thoracic facet joint(s) for chronic pain. Additional well designed comparative studies are needed to determine the effects of this technology on net health outcomes. Also, the 2013 evidence based guideline by American Society of Interventional Pain Physicians (ASIPP) recommendations states the evidence for radiofrequency neurotomy (ablation/denervation) is limited. Therefore, radiofrequency ablation (RFA)/denervation for thoracic facet joint(s) is considered investigational.

 

Radiofrequency Ablation (RFA)/Denervation of Sacroiliac Joint Pain

Radiofrequency ablation (RFA)/denervation is considered investigational for the treatment of sacroiliac joint pain.

 

Based on review of the peer reviewed medical literature, the literature on radiofrequency ablation (RFA)/denervation of the sacroiliac joint is limited to small randomized controlled trials, observational studies and systematic reviews. There are small randomized controlled trials (RCTs) that report short term benefit, but these are insufficient to determine the overall effect on net health outcomes. Further high quality controlled trials are needed that compare this procedure in defined populations with placebo and with alternative treatments. Also, the 2013 evidence based guideline by American Society of Interventional Pain Physicians (ASIPP) recommendations states the evidence for radiofrequency neurotomy (denervation/ablation) is limited. The current evidence on sacroiliac joint radiofrequency ablation (RFA)/denervation is insufficient to permit conclusions regarding the effect of this procedure on net health outcomes and therefore is considered investigational for the treatment of sacroiliac joint pain.

 

Alternative Methods of Denervation/Ablation in the Treatment of Facet Joint Pain and Sacroiliac Joint Pain   

All other methods of  ablation/denervation for the treatment of chronic neck and spinal/back pain, including but not limited to facet joint or sacroiliac joint pain are considered investigational (not an all-inclusive list):

  • Laser denervation,
  • Chemical neurolysis (chemodenervation) (e.g. alcohol, phenol, glycerol or hypertonic saline)
  • Cryodenervation (cryoablation)
  • Cooled radiofrequency (includes but is not limited to COOLIEF radiofrequency  i.e. cooled radiofrequency for cervical, lumbar and thoracic; Sinergy sacroiliac cooled radiofrequency)
  • Pulsed radiofrequency

Based on review of the peer reviewed medical literature there is insufficient evidence regarding the use of laser denervation, chemical neurolysis (chemodenervation), cryodenervation (cyroablation), cooled radiofrequency denervation/ablation (including but not limited COOLIEF radiofrequency) and pulsed radiofrequency for the treatment of the facet joint pain and sacroiliac joint pain. Long term controlled studies are lacking. Additional randomized controlled clinical trials with larger patient populations are needed. The evidence is insufficient to demonstrate the safety and long term efficacy to support the use of these techniques in the treatment of facet joint pain and sacroiliac joint pain.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis 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

 

Selected References:

  • Tzaan W-C, Taskere RR. Percutaneous radiofrequency facet rhizotomy-experience with 118 procedures and reappraisal of its value. Canadian Journal of Neurological Sciences 2002;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 Institute. External SiteRadiofrequency Neuroablation for Low Back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 May 19. 13p. (ECRI Hotline Response).
  • 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. External SiteRadiofrequency Neuroablation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2009 Sept 30. 12 p. [ECRI hotline response].
  • ECRI Institute. External SiteRadiofrequency Neuroablation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2010 Jul 2111 p. [ECRI hotline response]. 
  • 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. External SiteRadiofrequency Denervation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2011 August 8. [Hotline Response].
  • ECRI Institute. External Site2012 October, Hotline Response, Radiofrequency Denervation for Treating Chronic Low Back Pain.
  • American Society of Interventional Pain Physicians (ASIPP). 2013 Practice Guidelines for Chronic Spinal Pain. Pain Physician 2013;16:S49-S283
  • 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. External Site Subacute and chronic low back pain: nonsurgical interventional treatment. Roger Chou M.D., Topic last updated June 21, 2017 
  • 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. External SiteRadiofrequency Treatment in Chronic Pain.
  • Gupta Anita D.O., PharmD, Evidence Based Review of Radiofrequency Ablation Techniques for Chronic Sacral Iliac Joint Pain, PainMedicine News June 2010
  • UpToDate. External SiteTreatment of Neck Pain, Zacharia Isaac, M.D., Topic last updated December 21, 2015.
  • UpToDate. External SiteSubacute and Chronic Low Back Pain: Nonsurgical Interventional Treatment, Roger Chou, M.D., Topic last updated May 13, 2014.
  • Kok-Yuen Ho, Mohamed Abdul Hadi, et. al. Cooled Radiofrequency Denervation for Treatment of Sacroiliac Joint Pain: Two Year Results from 20 Cases, J Pain Res. 2013; 6:505511
  • Stelzer Wolfgang M.D, Aiglesberger Michael, BScN, et. al. Use of Cooled Radiofrequency Lateral Branch Neurotomy for the Treatment of Sacroiliac Joint Mediated Low Back Pain: A Large Case Series, Pain Medicine, Volume 14, Issue 1 pages 29-35, January 2013
  • Patel Nilesh M.D., Gross Andrew M.D. et. al, A Randomized, Placebo Controlled Study to Assess the Efficacy of Lateral Branch Neurotomy for Chronic Sacroiliac Joint Pain, Pain Medicine Volume 13, Issue 3, Pages 383-398 March 2012
  • Haktan Karaman, Gonul Olmex Kavak, et. al. Cooled Radiofrequency for Treatment of Sacroiliac Joint Pain, Acta Neurochirurugica, July 2011, Volume 153, Issue 7, pages 1461-1468
  • American Acadey of Neurology and American Headache Society, Evidence Based Guideline Update: NSAIDs and other Complementary Treatments for Episodic Migraine Prevention in Adults. Neurology 2012;78:1346-1363 - This guideline has been retired and is considered no longer valid and no longer supported by the AAN.
  • Falco FJ, Datta S, Manchikanti L, et al. An updated review of the diagnostic utility of cervical facet joint injections. Pain Physician. Nov-Dec 2012;15(6):E807-838. PMID 23159977
  • Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician. Nov-Dec 2012;15(6):E839-868. PMID 23159978
  • Falco FJ, Manchikanti L, Datta S, et al. An update of the systematic assessment of the diagnostic accuracy of lumbar facet joint nerve blocks. Pain Physician. Nov-Dec 2012;15(6):E869-907. PMID 23159979
  • Falco FJ, Manchikanti L, Datta S, et al. An update of the effectiveness of therapeutic lumbar facet joint interventions. Pain Physician. Nov-Dec 2012;15(6):E909-953. PMID 23159980
  • Boswell MV, Manchikanti L, Kaye AD, et al. A best-evidence systematic appraisal of the diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain. Pain Physician. Jul-Aug 2015;18(4):E497-533. PMID 26218947
  • Cohen SP, Strassels SA, Kurihara C, et al. Randomized study assessing the accuracy of cervical facet joint nerve (medial branch) blocks using different injectate volumes. Anesthesiology. Jan 2010;112(1):144-152. PMID 19996954
  • Cohen SP, Stojanovic MP, Crooks M, et al. Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J. May-Jun 2008;8(3):498-504. PMID 17662665
  • Pampati S, Cash KA, Manchikanti L. Accuracy of diagnostic lumbar facet joint nerve blocks: a 2-year follow-up of 152 patients diagnosed with controlled diagnostic blocks. Pain Physician. Sep-Oct 2009;12(5):855-866. PMID 19787011
  • Manchikanti L, Pampati S, Cash KA. Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks: an assessment of the implications of 50% relief, 80% relief, single block, or controlled diagnostic blocks. Pain Physician. Mar-Apr 2010;13(2):133-143. PMID 20309379
  • 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. Jul-Aug 2015;18(4):E535-582. PMID 26218948
  • Civelek E, Cansever T, Kabatas S, et al. Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain. Turk Neurosurg. 2012;22(2):200-206. PMID 22437295
  • Lakemeier S, Lind M, Schultz W, et al. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg. Jul 2013;117(1):228-235. PMID 23632051
  • Nath S, Nath CA, Pettersson K. Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double-blind trial. Spine (Phila Pa 1976). May 20 2008;33(12):1291-1297; discussion 1298. PMID 18496338
  • van Wijk RM, Geurts JW, Wynne HJ, 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. Jul-Aug 2005;21(4):335-344. PMID 15951652
  • Haspeslagh SR, Van Suijlekom HA, Lame IE, et al. Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache [ISRCTN07444684]. BMC Anesthesiol. 2006;6:1. PMID 16483374
  • Husted DS, Orton D, Schofferman J, et al. Effectiveness of repeated radiofrequency neurotomy for cervical facet joint pain. J Spinal Disord Tech. Aug 2008;21(6):406-408. PMID 18679094
  • Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine (Phila Pa 1976). Nov 1 2004;29(21):2471-2473. PMID 15507813
  • Rambaransingh B, Stanford G, Burnham R. The effect of repeated zygapophysial joint radiofrequency neurotomy on pain, disability, and improvement duration. Pain Med. Sep 2010;11(9):1343-1347. PMID 20667024
  • Smuck M, Crisostomo RA, Trivedi K, et al. Success of initial and repeated medial branch neurotomy for zygapophysial joint pain: a systematic review. PM R. Sep 2012;4(9):686-692. PMID 22980421
  • Hashemi M, Hashemian M, Mohajerani SA, et al. Effect of pulsed radiofrequency in treatment of facet-joint origin back pain in patients with degenerative spondylolisthesis. Eur Spine J. Sep 2014;23(9):1927-1932. PMID 24997616
  • Van Zundert J, Patijn 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. Jan 2007;127(1-2):173-182. PMID 17055165
  • Tekin I, Mirzai H, Ok G, et al. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin J Pain. Jul-Aug 2007;23(6):524-529. PMID 17575493
  • Kroll HR, Kim D, Danic MJ, et al. A randomized, double-blind, prospective study comparing the efficacy of continuous versus pulsed radiofrequency in the treatment of lumbar facet syndrome. J Clin Anesth. Nov 2008;20(7):534-537. PMID 19041042
  • Joo YC, Park JY, Kim KH. Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain. J Anesth. Jun 2013;27(3):390-395. PMID 23192698
  • Haufe SM, Mork AR. Endoscopic facet debridement for the treatment of facet arthritic pain--a novel new technique. Int J Med Sci. 2010;7(3):120-123. PMID 20567612
  • Manchikanti L, Singh V, Falco FJ, et al. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. Sep-Oct 2010;13(5):437-450. PMID 20859313
  • Manchikanti L, Singh V, Falco FJ, et al. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010;7(3):124-135. PMID 20567613
  • Manchikanti L, Singh V, Falco FJ, et al. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. Nov-Dec 2010;13(6):535-548. PMID 21102966
  • Manchikanti L, Singh V, Falco FJ, et al. The role of thoracic medial branch blocks in managing chronic mid and upper back pain: a randomized, double-blind, active-control trial with a 2-year followup. Anesthesiol Res Pract. 2012;2012:585806. PMID 22851967
  • Watters WC, 3rd, Resnick DK, Eck JC, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2014; 21(1):79-90. 2014/07/02:http://thejns.org/doi/abs/10.3171/2014.4.SPINE14281.
  • 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. Apr 2010;112(4):810-833. PMID 20124882
  • National Institute for Health and Clinical Excellence External Site (NICE). Early management of non-specific low back pain. Clinical guideline 88 2009.
  • California Technology Assessment Forum External Site (CTAF). Percutaneous radiofrequency neurotomy for treatment of chronic pain from the upper cervical (C2-3) spine. A Technology Assessment 2007.
  • Aydin SM, Gharibo CG, Mehnert M, et al. The role of radiofrequency ablation for sacroiliac joint pain: a metaanalysis. PM R. Sep 2010;2(9):842-851. PMID 20869684
  • Cohen SP, Hurley RW, Buckenmaier CC, 3rd, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. Aug 2008;109(2):279-288. PMID 18648237
  • Patel N. Twelve-Month Follow-Up of a Randomized Trial Assessing Cooled Radiofrequency Denervation as a Treatment for Sacroiliac Region Pain. Pain Pract. 2016 Feb;16(2):154-67. PMID 25565322
  • Zheng Y, Gu M, Shi D, et al. Tomography-guided palisade sacroiliac joint radiofrequency neurotomy versus celecoxib for ankylosing spondylitis: a open-label, randomized, and controlled trial. Rheumatol Int. Sep 2014;34(9):1195-1202. PMID 24518967
  • Van Tiiburg CW, Schuurmans FA, Stonks DL, et. al. Randomized Sham-controlled double blinded multicenter clinical trial to ascertain the effect of percutaneous radiofrequency treatment for sacroiliac joint pain: three month results. Clin J Pain 2016 Nov;32(11):921-926. PMID 26889616
  • UpToDate. Cervicogenic Headache. Zahid H. Bajwa M.D., James C. Watson M.D., Topic last updated May 2, 2016.
  • Juch J, Maas E, Ostelo R, et. al. Effects of radiofrequency denervation on pain intensity among patients with chronic low back pain the mint randomized clinical trials. JAM 2017;318(1):68-81
  • COOLIEF.

 

Policy History:

  • August 2017 - Annual Review, Policy Revised
  • August 2016 - Annual Review, Policy Revised
  • May 2016 - Annual review, Policy Revised
  • November 2015 - Interim review, Policy Revised
  • September 2015 - Interim review, Policy Revised
  • June 2015 - Annual review, Policy Revised
  • July 2014  - Annual review, Policy Renewed
  • September 2013 - New Policy
  • September 1, 2012 - Policy Retired
  • April 2012, Annual review, Policy Renewed
  • May 2011, Annual review, Policy Renewed

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.

 

*CPT® is a registered trademark of the American Medical Association.