Medical Policy: 07.01.58 

Original Effective Date: July 2002 

Reviewed: August 2018 

Revised: August 2018 

 

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:

Radiofrequency Ablation (RFA)

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 (MBB). Based on the American Society of Interventional Pain Physicians (ASIPP) 2013 evidence based guidelines for interventional techniques in chronic spinal pain, states “based on the available evidence it appears the best response is obtained after confirmation of the diagnosis of facet joint pain with controlled diagnostic blocks preferably with 75% pain relief as the criterion standard with dual blocks.” The goal of facet joint radiofrequency 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.

 

Radiofrequency Ablation for 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.

 

Summary

Based on the review of the peer reviewed medical literature no controlled trials evaluating radiofrequency ablation (RFA) in thoracic facet joints were identified. The literature includes observational studies. 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 facet joint 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. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Radiofrequency Ablation for 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.

 

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

Aydin et. al. (2010) published a meta-analysis of radiofrequency ablation (RFA) for sacroiliac (SI) joint pain. Ten articles ranging from inception to January 1, 2010, were found. The main outcome measure was a reduction of pain by ≥50% post-RFA procedure. At 3 months, 7 groups met the criteria and at 6 months, 6 groups met the criteria. A meta-analysis with a forest plot was done at the 3 and 6 month patient follow-up intervals. The associated standard error was calculated for each study group. An overall weighted average with respective standard error was also obtained. A calculation of 95% confidence intervals (95% CI) was then derived. A test for heterogeneity, publication bias, and file drawer effect was also done at the 3 and 6 month intervals. At 3 months, a range of 0.538-0.693 was found to have a 95% CI, with a pooled mean of 0.616. At 6 months, a 95% CI of 0.423-0.576 was found, with a pooled mean of 0.499. The meta-analysis demonstrated that RFA is an effective treatment for SI joint pain at 3 months and 6 months. The authors concluded, this study is limited by the available literature and lack of randomized controlled trials. Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials.

 

No additional studies were identified in the 2013 American Society of Interventional Pain Physicians (ASIPP) evidence review, which concluded that evidence was limited for conventional radiofrequency neurotomy, limited for pulsed radiofrequency neurotomy, and fair for cooled radiofrequency neurotomy.

 

Randomized Controlled Trials

In 2012, Patel et. al. reported a randomized, double-blind, placebo-controlled trial of lateral branch neurotomy with a cooled radiofrequency probe. Twelve-month follow-up was reported in 2016 (Patel et. al.). Fifty-one patients who had a positive response to 2 lateral branch blocks were randomized 2:1 to lateral branch radiofrequency or to sham. At 3-month follow-up, significant improvements were observed in pain levels (-2.4 vs -0.8), physical function (14 vs 3), disability (-11 vs 2), and quality of life (0.09 vs 0.02) for radiofrequency treatment compared with controls (all respectively). With treatment success defined as a 50% or greater reduction in numeric rating scale score, 47% of radiofrequency-treated patients and 12% of sham-treated patients achieved treatment success. The treatment response was durable to 12 months in the 25 of 34 patients who completed all follow-up visits.15 Of the 9 patients who terminated study participation, 4 (12%) of 34 were considered treatment failures.

 

In 2014, Zheng et. al. reported an randomized controlled trial (RCT) of palisade sacroiliac radiofrequency ablation (RFA) in 155 patients with ankylosing spondylitis. Palisade RFA uses a row of radiofrequency cannulae perpendicular to the dorsal sacrum. Inclusion criteria were ages 18 to 75 years; diagnosis of ankylosing spondylitis; chronic low back pain for at least 3 months; axial pain below L5; no peripheral involvement; pain aggravation on manual pressing of the sacroiliac joint (SIJ) area; and at least 50% pain relief following fluoroscopically guided anesthetic injection into the joint. Patients who met the inclusion criteria were randomized to palisade RFA or celecoxib. Blinded evaluation to 24 weeks found that RFA (2.8) resulted in lower global VAS (visual analog) scores than celecoxib (5.0; p<0.001) as well improved scores for secondary outcome measures. This study lacked a sham control.

 

In 2016, van Tilburg et. al. reported a sham-controlled randomized trial of percutaneous radiofrequency ablation (RFA) in 60 patients with sacroiliac joint (SIJ) pain. Patients selected had clinically suspected SIJ pain and a decrease of 2 or more points on a 10-point pain scale with a diagnostic sacroiliac block. Treatment group: percutaneous radiofrequency (RF) heat lesion at the lateral branches of S1, S2, S3, and S4 nerve roots and the posterior ramus dorsalis of L5; sham group: same procedure as the treatment group except for the radiofrequency (RF) heat lesion. No statistically significant differences in pain level over time between the groups (Group×Period) (F1,58=0.353; P=0.56) nor within the treatment Group (F1,58=0.212; P=0.65) were found. The Period factor, however, yielded a significant difference (F1,58=61.67; P<0.001), that is, when pooled together the mean pain level of the patients was significantly reduced at T1 compared with T0. In the crossover group, 42.1% experienced a reduction in NRS of 2 or more at 1 month (P=0.65). No statistically significant difference in satisfaction over time between the groups was found (F1,50=2.1; P=0.15). The independent factors Group (F1,50=2.02; P=0.16) and Period (F1,50=0.95; P=0.33) also showed no statistically significant difference. The same applies to recovery: no statistically significant Group×Period effect (F1,51=0.09; P=0.77) was found, neither an effect of Group (F1,51=0.004; P=0.95) nor of Period (F1,51=0.27; P=0.60). The authors concluded the hyopthesis of no difference in pain reduction or in Global Preceived Effect between the treatment and sham group cannot be rejected.

 

In 2017, Juch et. al. reported on a non-blinded multicenter randomized controlled trial (RCT) of radiofrequency denervation in patients with suspected sacroiliac joint pain unresponsive to conservative care who were asked to participate in the trial. All participants received a 3 month standardized exercise program and psychological support if needed. Participants in the intervention group received radiofrequency denervation as well. This is usually a one-time procedure, but the maximum number of treatments in the trial was three. The primary outcome was pain intensity (numeric rating scale, 0-10; whereby 0 indicated no pain and 10 indicated worst pain imaginable) measured 3 months after the intervention. The prespecified minimal clinically important difference was defined as 2 points or more. Final follow-up was at 12 months, ending October 2015. Among 681 participants who were randomized (mean age, 52.2 years; 421 women [61.8%], mean baseline pain intensity, 7.1), 599 (88%) completed the 3-month follow-up, and 521 (77%) completed the 12-month follow-up. The mean difference in pain intensity between the radiofrequency denervation and control groups at 3 months was -0.18 (95% CI, -0.76 to 0.40) in the facet joint trial; -0.71 (95% CI, -1.35 to -0.06) in the sacroiliac joint trial; and -0.99 (95% CI, -1.73 to -0.25) in the combination trial. The authors concluded, in 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources.

 

Summary

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 evidence is insufficient to determine the effects of the techology on net health outcomes.

 

Alternative Methods of Ablation/Denervation in the Treatment of Facet Joint Pain (Cervical, Thoracic, and Lumbar) and Sacroiliac Joint Pain

Alternative methods of ablation/denervation in the treatment of facet joint pain and sacroiliac joint pain (cervical, thoracic, and lumbar) 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, pulsed radiofrequency ablation and endoscopic radiofrequency ablation.

 

Laser Denervation

Laser denervation involves the use of a high intensity laser to denervate or destroy the nerves related to facet joint pain (cervical, thoracic, or lumbar) or sacroiliac 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. There are no comparative studies for the use of laser denervation to treat facet joint (cervical, thoracic, and lumbar) pain or sacroiliac joint pain. Additional research is needed to assess the effectiveness of controlled trials are needed to evaluate this alternative treatment method. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Chemical Neurolysis (Chemodenervation)

Chemical neurolysis also referred to as chemical ablation, chemodenervation 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 (cervical, thoracic, and lumbar) and sacroiliac joint pain relief. The chemical ablating agent is injected into the facet joint nerve or sacroiliac joint, the damage to the nerve tissue reduces its ability to transmit pain signals, thereby reducing pain sensation. However, there is lack of published data to support the safety and efficacy of this technique in the treatment of facet joint pain (cervical, thoracic, and lumbar) or for sacroiliac joint pain.

 

Joo et. al. (2013), compared alcohol ablation with radiofrequency ablation in a randomized study of 40 patients with recurrent thoracolumbar facet joint pain following an initial successful radiofrequency ablation. At 24 month follow-up, three patients in the alcohol ablation group had recurring pain compared to 19 in the radiofrequency group. The median effective periods were 10.7 months (range 5.4 to 24) for radiofrequency and 24 months (range 16.8 to 24) for alcohol ablation. No significant complications were identified. Given the possibility of harm as described in professional society recommendations on chemical denervation additional studies are needed.

 

Cryodenervation (Cryoablation)

Cryodenervation (cryoablation) is a minimally invasive procedure that involves the use of extreme cold to destroy abnormal tissue. 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 (cervical, thoracic, and lumbar) or for sacroiliac joint pain, further studies are needed.

 

Birkenmaier et. al. (2007) conducted a prospective clinical case series to examine the effects of medial branch cryodenervation (cryoablation) in the treatment of lumbar facet joint pain. Patient selection was based on medical history, physical examination and positive medial branch blocks. Percutaneous medial branch cryodenervation was performed using a Lloyd Neurostat 2000. Target parameters were low back pain (by means of visual analog scale [VAS]), limitation of activity (McNab) and overall satisfaction. A total of 50 patients were recruited, and 46 completed the study. The follow up time was 1 year. At 6 weeks, 33 patients (72%) were pain free or had major improvements of low back pain; 13 (28%) had no or little improvement. The mean low back pain decreased from 7.7 pre-operatively to 3.2 at 6 weeks, 3.3 at 3 months, 3.0 at 6 months and 4.2 at 12 months. However, the authors noted that at the 12 month follow-up period the failure rate rose to 43%.

 

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 (cervical, thoracic and lumbar).

 

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 (cervical, thoracic, and lumber) or for 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 to include facet joint pain (cervical, thoracic, and lumbar) and sacroiliac joint pain. 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).

 

Pulsed radiofrequency (RF) denervation was compared with steroid injection in a randomized trial of 80 patients (Hashemi et. al. 2014). Patients were randomly assigned to one of two groups: group one received pulsed RF, and group 2 received injection by steroids (triamcinolone) and bupivacaine. Multiple outcome measures were utilized which included the numeric rating scale (NRS), the Oswestry Disability Index (ODI), satisfaction status, and analgesic intake with assessment at 3, 6, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as reduction of 40% or more. Eighty patients were enrolled in the study and were divided into the two groups of study. PRF significantly reduced NRS at 6-month follow-up compared to steroid + bupivacaine. 75.6 ± 14.3% at pre-treatment and 19.3 ± 9.5% at 6 months (p = 0.001) in PRF group. The mean ODI is depicted in two groups of study (Fig. 1). Interestingly, ODI% was significantly lower in PRF group at 12 weeks and 6 months compare to steroid + bupivacaine group (p = 0.022 and 0.03, respectively), but it was not significantly different at 6 weeks (p = 0.31). Proportion of patients who did not require analgesics were significantly higher in PRF group compared to other group (p = 0.001) in Log-rank (Mantel-Cox) test. The authors concluded, our results demonstrated that the application of pulsed radiofrequency might be more effective then steroid and bupivacaine injection in decreasing back pain due to degenerative facet pain and improvement in function of patients.

 

In 2008, Kroll et. al. compared the efficacy of continuous radiofrequency (CRF) with pulsed radiofrequency (PRF) in the treatment of lumbar facet syndrome. The study design was prospective, randomized, double blinded study with 50 patients. Target facet joints were identified with oblique radiographic views. Continuous radiofrequency thermocoagulation was delivered at 80 degrees C for 75 seconds, while PRF was delivered at 42 degrees C with a pulse duration of 20 ms and pulse rate of two Hz for 120 seconds. Visual analog scale (VAS) pain assessment and Oswestry Low Back Pain and Disability Questionnaire (OSW) were administered at baseline and then at three months. Comparisons between groups and within groups were made of the relative percentage improvement in VAS and OSW scores. No significant differences in the relative percentage improvement were noted between groups in either VAS (P = 0.46) or OSW scores (P = 0.35). Within the PRF group, comparisons of the relative change over time for both VAS (P = 0.21) and OSW scores (P = 0.61) were not significant. However, within the CRF group, VAS (P = 0.02) and OSW scores (P = 0.03) showed significant improvement. The authors concluded, although there was no significant difference between CRF and PRF therapy in long-term outcome in the treatment of lumbar facet syndrome, there was a greater improvement over time noted within the CRF group.

 

In 2007, Van Zundert et. al. randomized 23 patients (of 256 screened) with chronic cervical radicular pain to pulsed radiofrequency (RF) or sham treatment. Success was defined as 50% or more improvement on global perceived effect (GPE), 20% or more reduction in VAS (visual analogue scale) pain, and reduced pain medication use measured 3 months after treatment. Eighty-two percent of patients in the treatment arm and 33% in the sham arm showed at least 50% improvement on GPE (p=0.03) and 82% in the treatment group and 27% in the sham group achieved at least 20% reduction in VAS pain (p=0.02).

 

In 2007 study by Tekin et. al. patients were randomized 20 each to conventional radiofrequency (RF), pulsed radiofrequency (RF), or a control group (local anesthetic only). Outcome measures were pain measured on VAS (visual analogue scale) and Oswestry Disability Index (ODI) scores. Mean VAS and ODI scores were lower in both treatment groups than in controls post-treatment; however, reductions in pain were maintained at 6 and 12 month follow-up only in the conventional RF group. The number of patients not using analgesics and patient satisfaction were highest in the conventional RF group.

 

Summary

Studies for pulsed radiofrequency ablation are limited, and insufficient to support conclusions regarding efficacy of duration of effect. Additional, well-designed, longer-term randomized controlled trials (RCTs) are required to evaluate the safety and efficacy of continuous radiofrequency ablation and pulsed radiofrequency ablation and to compare these techniques with other medical and surgical therapies for chronic facet joint pain (cervical, thoracic, and lumbar) and for sacroiliac joint pain. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Endoscopic Radiofrequency Ablation

An endoscopic radiofrequency ablation is a minimally invasive procedure in which the nerves that innervate the facet joints are transected and then ablated through a small tube using small instruments. This procedure is an outpatient procedure usually performed under light sedation. The procedure offers another means of pain relief for facet joint related pain. This procedure is an alternative to percutaneous radiofrequency ablation, where either the patient has disease that may appear to not be amendable to the percutaneous approach, such has patients with severe facet joint disease, history of lumbar fusion, or severe scoliotic curvature and have had a positive response to the diagnostic medial branch block (MBB). The endoscopic radiofrequency is also an option for patients that have recurrent pain after 6-9 months of relief with the percutaneous radiofrequency ablation and do not wish to repeat the percutaneous approach.

 

Special equipment is used including fluoroscope and a monitor to view the spine through the scope, and small instruments are used to ablate the nerves. A small incision is made over the facet joint and after local anesthetic is administered, the port, which is the size of a small pen chamber, is passed onto the facet joint. A camera is inserted into the port along with instruments to transect and then ablate the medial branch nerves. Under direct visualization the nerve is localized and ablated. Once the nerve is ablated, the facet joint ineffectively transmits pain to the brain. When adequate nerve ablation has occurred, the tools are removed, a suture is placed under the skin and a bandage is placed.

 

A search of the medical peer reviewed literature did not identify any clinical studies that evaluated endoscopic radiofrequency ablation for the treatment of spinal pain (facet joint pain) or sacroiliac joint pain. The clinical outcomes from a pilot study evaluating this technology were presented as a professional society conference abstract, Yueng et. al. 2011. There is insufficient evidence in the published medical literature to determine the safety and efficacy of this emerging alternative modality or approach compared to percutaneous radiofrequency ablation for the treatment of spinal pain.

 

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), pulsed radiofrequency ablation and endoscopic radiofrequency ablation for the treatment of the facet joint pain (cervical, thoracic, and lumbar) and sacroiliac joint pain. Additional, well-designed, longer term randomized controlled clinical trials (RCTs) are required to evaluate the safety and efficacy of these alternative treatment methods and to compare these techniques with other medical and surgical therapies. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

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:

Cervical Spine
  • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intra-articular injections.

 

Lumbar Spine (Includes Sacroiliac Joint Pain):
  • For lumbar spine, the evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intra-articular injections.
  • 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 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, Chronic Headaches and Atypical Facial Pain* 07.01.66
  • Ablative Procedures of the Peripheral Nerves to Treat Pain* 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 no controlled trials evaluating radiofrequency ablation (RFA) in thoracic facet joints were identified. The literature includes observational studies. 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. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Radiofrequency Ablation (RFA)/Denervation of Sacroiliac Joint Pain

Radiofrequency ablation (RFA)/denervation is considered investigational for the treatment of sacroiliac joint (SIJ) 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 evidence is insufficient to determine the effects of the technology on net health outcomes.

Alternative Methods of Denervation/Ablation in the Treatment of Facet Joint Pain (Cervical, Thoracic, and Lumbar) 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 (cervical, thoracic, and lumbar) pain 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
  • Endoscopic radiofrequency ablation

 

Based on review of the peer reviewed medical literature there is insufficient evidence regarding the use these alternative treatment methods for the treatment of chronic neck and spinal/back pain, including but not limited to facet joint (cervical, thoracic and lumbar) pain or sacroiliac joint pain. Additional, well-designed, longer term randomized controlled clinical trials (RCTs) are required to evaluate the safety and efficacy of these alternative treatment methods and to compare these techniques with other medical and surgical therapies. The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

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. Radiofrequency 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. Radiofrequency Neuroablation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2009 Sept 30. 12 p. [ECRI hotline response].
  • ECRI Institute. Radiofrequency 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. Radiofrequency Denervation for Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2011 August 8. [Hotline Response].
  • ECRI Institute. 2012 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
  • 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.
  • 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 September 21, 2017.
  • UpToDate. Subacute and Chronic Low Back Pain: Nonsurgical Interventional Treatment, Roger Chou, M.D., Topic last updated June 21, 2018.
  • 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 PMID 22299761
  • 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 (NICE). Early management of non-specific low back pain. Clinical guideline 88 2009.
  • California Technology Assessment Forum (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 Tilburg 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 1, 2018.
  • 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.
  • ECRI. Coolief Sinergy Cooled Radiofrequency System (Halyard Health, Inc.) for Treating Sacroiliac Joint Pain. Published May 8, 2017. 
  • Yeung AT, Zheng Y. Endoscopic dorsal rhizotomy, a new anatomically guided MIS, is more effective than traditional pulsed radiofrequency lesioning for non-discogenic axial back pain. The International Society for the Advancement of Spine Surgery Annual Meeting 2011. 
  • Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med 2007;39(3):225-229. PMID 17345622 
  • Hansen H, Manchikanti L, Simopoulos TT, et. al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician 2012;15(3):E247-E278
  • Birkenmaier C, Veihelmann A, Trouillier H, et. al. Percutaneous cryo denervation of lumbar facet joints: a prospective clinical trial. Int Orthop 2007;31(4):525-530

 

Policy History:

  • August 2018 - Annual Review, Policy Revised
  • 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.