This version of the policy will become effective on 06/15/2020, and communicates Company's continuing medical policy position on Denervation of the Spinal Nerves for Chronic Pain.
Description section was updated and the last bullet of medical necessity was reworded for clarity.
For individuals who have suspected facet joint pain who receive diagnostic medial branch blocks, the evidence includes a systematic review of 17 diagnostic accuracy studies, a small randomized trial, and several large case series. Relevant outcomes are other test performance measures, symptoms, and functional outcomes. There is considerable controversy about the role of these blocks, the number of positive blocks required, and the extent of pain relief obtained. Studies have reported the use of single or double blocks and at least 50% or 80% improvement in pain and function. This evidence has suggested that there are relatively few patients who exhibit pain relief following 2 nerve blocks, but that these select patients may have pain relief for several months following RF denervation. Other large series have reported the prevalence and false-positive rates following controlled diagnostic blocks, although there are issues with the reference standards used in these studies because there is no criterion standard for the diagnosis of facet joint pain. There is level I evidence for the use of medial branch blocks for diagnosing chronic lumbar facet joint pain and level II evidence for diagnosing cervical and thoracic facet joint pain. The evidence available supports a threshold of at least 75% to 80% pain relief to reduce the false-positive rate.
For individuals who have facet joint pain who receive radiofrequency ablation, the evidence includes a systematic review of randomized controlled trials. Relevant outcomes are symptoms, functional outcomes, quality of life, and medication use. While evidence is limited to a few randomized controlled trials with small sample sizes, RF facet denervation appears to provide at least 50% pain relief in carefully selected patients. Diagnosis of facet joint pain is difficult. However, response to controlled medial branch blocks and the presence of tenderness over the facet joint appears to be reliable predictors of success. When RF facet denervation is successful, repeat treatments appear to have similar success rates and duration of pain relief. Thus, the data indicate that, in carefully selected individuals with lumbar or cervical facet joint pain, RF treatments can improve outcomes.
There is clinical supported the use of RF denervation for facet joint pain, and this support extends to use of 2 diagnostic blocks achieving a 50% reduction in pain.
For individuals who have facet joint pain who receive therapeutic medial nerve branch blocks or alternative methods of facet joint denervation, the evidence includes uncontrolled case series and randomized trials without a sham control. Relevant outcomes are symptoms, functional outcomes, quality of life, and medication use. Pulsed RF does not appear to be as effective as conventional RF denervation, and there is insufficient evidence to evaluate the efficacy of other methods of denervation (e.g., alcohol, laser, cryodenervation) for facet joint pain or the effect of therapeutic medial branch blocks on facet joint pain.
For individuals who have sacroiliac joint (SIJ) pain who receive radiofrequency ablation (RFA), the evidence includes 4 small RCTs using different radiofrequency applications and case series. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. For RFA with a cooled probe, the 2 small RCTs reported short-term benefits, but these are insufficient to determine the overall effect on health outcomes. The RCT on palisade RFA of the SIJ did not include a sham control. Another sham-controlled randomized trial showed no benefit of RFA. Further high-quality controlled trials are needed to compare this procedure in defined populations with sham control and alternative treatments.
THE FOLLOWING CODES ARE USED TO REPRESENT NON-PULSED RADIOFREQUENCY (RF) DENERVATION: 64633, 64634, 64635, 64636
THE FOLLOWING CODE IS USED TO REPRESENT RADIOFREQUENCY DENERVATION OF THE SACROILIAC JOINT: 64625