DESCRIPTION
A potential source of spinal pain is the posterior zygapophysial joint (facet, Z joint), which adjoins adjacent vertebrae and is innervated by medial branches of the dorsal spinal nerves at two levels. Diagnosis of facet joint syndrome can be confirmed when controlled local anesthetic blocks of the medial branches of the posterior rami of the spinal nerves that supply the painful joint(s) provides relief of the target pain. Treatment options after successful diagnostic nerve blocks include thermal radiofrequency denervation (neurotomy), also known as nonpulsed or thermal radiofrequency ablation (RFA). Conventional RFA involves the constant application of energy usually at 80 - 85 degrees Celsius via an image-guided needle electrode inserted percutaneously to the affected nerve.
Note: There are two facet joints per level, one on the right side and one on the left. This policy allows for a right side and a left side RFA without the six months in-between because they are being done at different joints.
POLICY
Thermal radiofrequency denervation (neurotomy) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
All other methods of radiofrequency medial branch denervation for the treatment of chronic neck/back pain, including, but not limited to, the following are considered investigational:
Pulsed radiofrequency denervation
Laser denervation
Chemical (e.g., alcohol, phenol, high-concentration local anesthetics)
Cryo-denervation
Endoscopic
MEDICAL APPROPRIATENESS
Thermal medial branch radiofrequency denervation (neurotomy) is considered medically appropriate when ALL of the following are met:
Presence of primarily axial cervical or lumbar pain, without radiculopathy or neurological deficits, that has been present for at least three months
Failure of at least three months non-operative treatment, including ALL of the following unless contraindicated:
Analgesic or anti-inflammatory medication
Activity modification
Chiropractic or physical therapy, or professionally-directed home exercise program
Imaging studies have ruled out other causes of spinal pain
No more than two levels (up to four facet joints/medial nerve branches) are treated
Planned procedure is indicated for ANY ONE of the following:
Initial neurotomy when two successful diagnostic medial branch blocks each result in greater than 80% reduction in pain and improvement in function for the expected duration of the analgesic
Repeat neurotomy at the same location(s) when there is a prior history of successful neurotomy (at least 50% reduction in pain and improvement in function for at least six months)
Absence of ALL of the following:
Infection at site planned for procedure
Prior spinal fusion at site planned for procedure
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Controlled trials are necessary to evaluate non-conventional radiofrequency ablation (laser, chemical, endoscopic, and cryo-denervation).
SOURCES
Chou R. (2010). Low back pain (chronic). BMJ Clinical Evidence, 1116. (Level 2 evidence)
Cohen S. P. (2015). Epidemiology, diagnosis, and treatment of neck pain. Mayo Clinic Proceedings, 90 (2), 284-299. Abstract retrieved January 6, 2022 from PubMed database.
Iannuccilli, J. D., Prince, E. A., & Soares, G. M. (2013). Interventional spine procedures for management of chronic low back pain-a primer. Seminars in Interventional Radiology, 30 (3), 307-317. (Level 5 evidence)
Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician, 16, S49-S283. (Level 2 evidence)
Rambaransingh B, Stanford G, & Burnham R. (2010). The effect of repeated zygapophysial joint radiofrequency neurotomy on pain, disability, and improvement duration. Pain Medicine,11 (9), 1343-1347. Abstract retrieved January 5, 2022 from PubMed database.
Smuck M, Crisostomo RA, Trivedi K, & Agrawal D. (2012). Success of initial and repeated medial branch neurotomy for zygapophysial joint pain: a systematic review. PM&R, 686-692.
TurningPoint Health Solutions. (2022). Radiofrequency ablation. Retrieved January 19, 2023 from TurningPoint Health Solutions.
van Kleef, M., Vanelderen, P., Cohen, S. P., Lataster, A., Van Zundert, J., & Mekhail, N. (2010). Pain originating from the lumbar facet joints. Pain Practice, 10 (5), 459-469. Abstract retrieved January 5, 2022 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/1999
MOST RECENT REVIEW DATE: 3/9/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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