Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Denervation of the Spinal Nerves for Chronic Pain

Policy #:11.15.09l

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin 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 Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Non-pulsed radiofrequency (RF) denervation of the cervical facet joints at or below C2 (i.e., 2nd level vertebra) and lumbar facet joints of the spine are considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The individual has a history of severe, disabling neck and/or back pain where other treatable causes of pain (e.g., tumors, infections, spinal stenosis, herniated discs, psychiatric etiology) have been ruled out; and the pain is suggestive of facet joint origin (as evidenced by absence of nerve root compression as documented in the medical record), and is not primarily radicular.
  • The individual has no prior spinal fusion surgery in the vertebral levels being treated with RF.
  • There is documented failure of three months or longer trial of conservative treatments (e.g., physical therapy, home exercise program, acetaminophen, manipulation, and/or non-steroidal anti-inflammatory medications).
  • A successful trial of controlled diagnostic facet joint blocks (i.e. medial branch blocks), consisting of two separate positive blocks conducted on different days with local anesthetic only (no steroids or other drugs) under image guidance resulted in a clinically significant improvement in pain and/or disability when compared to baseline assessment (i.e., 80 percent reduction in pain). No therapeutic intra-articular injections (i.e., steroids, saline, or other substances) should have been administered for at least 4 weeks prior to the diagnostic facet joint block.
  • If there was a prior successful RF denervation, a minimum time of 5 months has elapsed since the prior RF treatment (per side, per anatomical level of the spine):
    • Consideration may be given for repeated RF treatment at least 5 months, following a prior successful RF denervation, if the individual’s functional status, secondary to the return of pain, seriously impedes their ability to work or to care for their activities of daily living (i.e., at least 50% reduction in pain).

For each covered spinal region (cervical or lumbar), non-pulsed radiofrequency (RF) denervation is considered medically necessary and, therefore, covered only when performed at no more than four (4) joints per session (e.g., two [2] bilateral levels or four [4] unilateral levels).

EXPERIMENTAL/INVESTIGATIONAL

All other uses for radiofrequency facet joint denervation of spinal nerves, including, but not limited to, the treatment of chronic thoracic facet or sacroiliac (SI) joint pain, are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Pulsed radiofrequency (PRF) denervation of the spinal nerves for treatment of chronic pain is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

All other methods of denervation for the treatment of chronic spinal/back pain, including, but not limited to laser denervation, chemodenervation, and cryodenervation, are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Global Perceived Effect (GPE): scales used to provide a means of measuring self-perceived change in health status. The main purpose is to quantify the extent to which an individual feels they have improved or deteriorated over time.

Visual Analogue Scale (VAS): a psychometric response scale, which can be used in questionnaires, to measure subjective characteristics or attitudes. Individuals specify their level of agreement to a statement by indicating a position along a continuous line between two end-points.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, non-pulsed radiofrequency denervation of cervical and lumbar spinal nerves for chronic pain are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable benefit contract, pulsed radiofrequency (PRF) denervation of the spinal nerves for treatment of chronic pain is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for radiofrequency denervation of spinal nerves for chronic facet pain.

Description

Most back pain resolves with conservative treatment, but a significant number of individuals may develop chronic spinal pain. The causes of chronic back or neck pain are obscure, and imaging techniques are not dependable diagnostic tools. Nerve block studies indicate that nonspecific pain is often attributed to disorders of the facet (zygapophyseal) joint; however, nonspecific pain is a condition with no clear pathological etiology. Although no definitive treatment is available, conventional percutaneous radiofrequency (RF) denervation of the facet joint has been advocated and used with increasing frequency.

Radiofrequency (RF) lesioning (also known as RF ablation, RF facet denervation, RF rhizotomy, facet rhizotomy, and percutaneous RF neurotomy) for disorders of the facet joint is performed in an outpatient setting. RF denervation is used to treat back and neck pain originating in the facet joints with degenerative changes. Diagnosis of facet joint pain is confirmed by a positive response from nerve blocks. The goal of RF facet denervation is for long-term pain relief of the facet joint pressure.

The facet joints, also known as apophyseal or zygapophyseal joints, are formed by the superior and inferior articular processes of sequential vertebrae. On the dorsolateral surface of each superior articular facet is a prominence known as the mammillary body or process. The nerves that communicate with these joints sometimes become inflamed or impinged, which leads to pain.

There are two types of radiofrequency facet joint denervation used to treat chronic spinal pain. They are:
  • Pulsed radiofrequency (PRF), which consists of short bursts of electrical current of a high voltage, but without heating the tissue enough to cause coagulation.
  • Percutaneous or non-pulsed RF, which is performed for a predetermined amount of time with no interruption in the RF flow until the full dosing time is achieved.

PULSED RADIOFREQUENCY (RF)

Pulsed RF, a nonablative alternative to RF, uses short bursts of radiofrequency current, rather than a continuous current. The heat from pulsed RF is not enough to cause the tissue to coagulate. Pulsed radiofrequency denervation causes the transmission across small unmyelinated nerve fibers to be disrupted, but not permanently damaged. This is because the temperatures will not exceed 42 degrees Celsius, versus the 60 degrees Celsius reached in (thermal) percutaneous RF.

One small RCT was identified using pulsed RF. Van Zundert et al. (2007) conducted a randomized sham-controlled trial investigating the treatment of pulsed RF for the indication of chronic cervical radicular pain. The study included 23 participants who reported neck pain that radiated over the posterior shoulder to the arm and lasted more than 6 months; these participants had failed conservative therapy. The participants were assessed 3 months following the treatment. Success was defined as at least a 50% pain improvement of the global perceived effect (GPE), at least a 20% reduction in pain on the visual analog scale (VAS), and a reduction in pain medication consumption. Nine out of 11 participants in the treatment arm, and 4 out of 12 in the sham group, had at least a 50% pain improvement. Nine out of 11 in the treatment group, and 3 of the 12 in the sham group, achieved at least a 20% reduction in pain on VAS (P=0.2). At 6-month follow-up, there was an increase in participants in the treatment group who reduced their use of pain medication, but the difference was not significant. The authors concluded that pulsed RF may provide cervical pain relief for a limited number of select individuals, but larger studies are needed to validate this conclusion.

Although pulsed RF seemed to provide limited relief in select individuals, most studies revealed that those who received percutaneous RF experienced greater improvement over time than those treated with pulsed RF.

Most studies published on pulsed RF are composed of small case series and reports with limited follow-up. Additional larger RCTs on pulsed RF are needed to establish safety and effectiveness for use in treating chronic facet pain.

NON-PULSED (PERCUTANEOUS) RADIOFREQUENCY

Prior to having an RF denervation procedure, a diagnostic paravertebral facet joint nerve block is commonly performed to assess the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome. A diagnostic nerve block localizes the nerve(s) responsible for the pain or neuromuscular dysfunction, particularly when multiple sources of pain are potentially present. This procedure is performed under fluoroscopic guidance to ensure accurate placement of the needle in the facet joint or at the medial nerve branch of the facet joint.

Upon needle placement, a long-acting local anesthetic is injected to temporarily numb the facet joint. The individual is then asked to engage in the activities that had previously precipitated pain, and to evaluate the effect of the procedure at 4 to 8 hours post-injection. A temporary or prolonged absence of spinal pain strongly suggests that the facet joint is the source of the symptoms. A repeat injection may be needed to establish consistency of results, particularly if diagnostic nerve blocks are followed by neurolysis.

RF facet joint denervation employs a percutaneously introduced electrode that applies heat from radio waves to selectively destroy sensory afferent nerve fibers, thereby interrupting pain signals from a specific site. A minimum of two levels must be addressed to denervate a single joint; RF lesioning is directed at each of the levels to be lesioned. Destruction of the nerve may be permanent or temporary. In some cases, the treated nerve repairs itself and becomes less irritable, thus resulting in continued resolution of the pain. In cases where the pain returns, the procedure can be repeated in the same joint, following an elapsed time of at least 6 months and a previous positive result from RF denervation, as measured by significant improvement in functional status and reduced facet mediated pain.

PEER-REVIEWED LITERATURE
Lumbar Facet Joint Pain

A 2015 systematic review by Manchikanti et al identified 9 randomized controlled trials (RCTs) or comparative studies on RF denervation of lumbar facet joints. The sample sizes ranged from 31 to 100 subjects. All studies but one showed short- or long-term benefit of facet joint denervation, and the overall body of evidence was rated as level II.

The largest study included in Manchikanti’s systematic review compared facet joint injection and facet joint denervation in 100 subjects. There were no sham controls, limiting interpretation of the results. In a 2013 double-blind RCT by Lakemeier et al, RF facet joint denervation was compared with intra-articular steroid injections in 56 subjects. Subjects were selected first on magnetic resonance imaging findings of hypertrophy of the facet joints followed by a positive response to an intra-articular infiltration of the facet joints with anesthetics. A diagnostic double-block of the facet joint was not performed. At 6 months, there was no significant difference between the 2 groups.

Nath and associates performed an RCT involving 40 individuals, following a screening of 376 individuals, to evaluate short- and intermediate-term effects of RF for lumbar facet pain study data. Individuals who were included in the study complained of pain involving one or more lumbar zygapophysial joints, paravertebral tenderness, and had obtained at least an 80% reduction of pain following controlled medial branch blocks. The 40 participants were randomly assigned to an RF or sham group and were followed for 6 months. Multiple lesions were treated in each participant in the RF group. The GPE and VAS measurements were used to assess outcomes following treatment in both groups. While back pain was reduced in both groups, the RF participants were significantly more improved on secondary measures of back and hip movement, quality-of-life variables, paravertebral tenderness, and reduction in use of analgesics.

In 2005, van Wijk et al. performed a multicenter randomized controlled study. Inclusion criteria was continuous low back pain with or without radiating pain to the upper leg greater than 6 months, as well as tenderness over the facet joints. A total of 226 participants were screened for the study. Of those screened, 81 were randomly assigned to either an RF group (40) or a sham treatment group (41). The primary outcome was determined by defined outcome measures using a visual analog scale (VAS), (a psychometric response scale that can be used to measure subjective characteristics or attitudes), daily physical activities, and individual use of analgesics. Success was defined as 50% reduction of the median VAS-back score without reduction in daily activities and/or increase in analgesic use or reduction of at least 25% in a participant's analgesic use. Participants kept weekly diaries and were followed up at 3 months. Failures at 3 months in the sham group were unblinded and offered RF. Follow-up then continued at 6, 9, and 12 months. At 3 months there was no difference between the two groups. Although some participants were lost to follow-up between 3 months and 12 months, the authors' overall conclusion was that significantly more participants in the RF group than the sham group achieved greater than 50% pain relief on the Global Perceived Effect (GPE) measure, which used a 4-point Lickert scale.

The available peer-reviewed data, including the aforementioned studies, suggest that RFA has improved outcomes related to pain and functional status when used for the treatment of lumbar facet pain in selected individuals.

Cervical Facet Joint Pain

An RCT published in 1995 by Lord et al. utilized RFA to treat chronic cervical pain of the facet joints. (Individuals with C2-C3 zygapophyseal joint pain were excluded due to the technical difficulty in treating this level of pain.) Of the 54 screened individuals, 24 participants met the inclusion criteria and were randomly assigned to an RFA or sham group. The individuals' perception of pain was confirmed using placebo-controlled blocks. In the RFA group, two or three thermal lesions using RFA were made at each cervical location being treated. Participants were followed for the first few days, then weeks, and then again at 3 months using a VAS measurement and the McGill pain questionnaire, indicating whether activities of daily living had been restored. Those from either group who had no relief of pain or an early return of pain were offered RFA. Those who had pain relief at 3 months were asked to follow up when their pain returned to 50% or more of their pretreatment level. The results were an average return to greater than 50% of pretreatment pain at 263 days in the RFA group versus 8 days in the placebo group.

The data suggest certain selected individuals would benefit from RFA in treating cervical facet joint pain.

Thoracic Facet Joint Pain

There is a current paucity of high-quality data evaluating the safety and effectiveness of treatment with RF denervation in the thoracic facet joints for chronic pain.

Sacroiliac Joint Pain

The literature on radiofrequency denervation of the sacroiliac joint is limited. Two small RCTs using a cooled radiofrequency probe were identified. A third RCT used palisade sacroiliac joint radiofrequency neurotomy.

In 2010, Aydin et al. published a meta-analysis of radiofrequency ablation (RFA) for sacroiliac pain. Nine studies were reviewed that reported the primary outcome measure of a reduction of pain of 50% or greater, assessed using VAS. This included a randomized placebo controlled study, three prospective observational studies, and five retrospective studies. All of the studies used injection of local anesthetic to determine if RFA was indicated for the individual. Seven studies reported follow-up treatment to 3 months, and 6 studies reported follow-up to 6 months. Meta-analysis indicated that at least half of the individuals who received RFA at the sacroiliac joint showed a reduction in their pain of 50% or more at 3 and 6 months. The conclusion determined by the meta-analysis review of this literature is limited by the low quality of the studies and lack of RCTs. In addition, the authors concluded, no standards have been established for the specific nerves to ablate or type of technique.

The single RCT included in the meta-analysis by Aydin et al. examined the effect of lateral branch radiofrequency denervation in 28 patients with injection-diagnosed sacroiliac joint pain. Two (14%) of 14 patients in the placebo-control group reported pain relief at 1-month follow-up. None reported benefit at 3-month follow-up. Of 14 patients treated with radiofrequency denervation, 11 (79%) reported pain relief at 1 month, 9 (64%) at 3 months, and 8 (57%) at 6 months.

In 2012, Patel et al. published results from a double-blind placebo controlled trial designed to compare the efficacy of lateral branch neurotomy using cooled radiofrequency to a sham intervention for the treatment of sacroiliac joint pain. The authors randomized N=51 individuals with had a positive response to 2 lateral branch blocks to lateral branch radiofrequency or sham treatment at a 2:1 ratio. The primary outcomes were pain, physical function, disability, quality of life and treatment success. Significant improvements in pain (-2.4 vs -0.8), physical function (14 vs 3), disability (-11 vs 2), and quality of life (0.09 vs 0.02) were observed for radiofrequency treatment compared with controls at the 3-month follow-up point. Treatment success was defined as a 50% or greater reduction in the numeric rating scale (NRS). Using this definition, 47% of radiofrequency-treated patients and 12% of sham patients achieved treatment success.

In a subsequent publication the Patel et al. workgroup reported that the treatment response was maintained out to 12 months in among the 25 of 34 patients who completed all follow-up visits. Of the 9 patients who terminated study participation, 4 were considered treatment failures (12% of 34).

In 2014, Zheng et al reported a RCT of palisade sacroiliac RFA in 155 subjects with ankylosing
spondylitis. Palisade RFA uses a row of radiofrequency cannulae perpendicular to the dorsal sacrum. Study participants were randomized to either palisade RFA or celecoxib. Blinded evaluation found that RFA resulted in lower global VAS scores compared with celecoxib (2.8 vs 5.0, respectively, p<0.001), as well improved scores for secondary outcome measures. This study is limited by the lack of a sham control.

Additional, larger, well-designed trials are needed for comparing specific procedures in defined populations to for use in sacroiliac pain.

Repeat Procedures

Two retrospective small series studies (Schofferman J, Kine G, 2004; Husted DS et al, 2008) were found (20 and 24 participants, respectively) involving the use of repeat RF procedures. In both studies, over 80% of participants had greater than 50% relief from repeat RF treatment. The duration of pain relief following the repeat RF was comparable to the duration of relief from the initial RF treatment. Since then, similar outcomes using repeat RF have been observed.

A 2012 systematic review of 16 studies of repeated medial branch neurotomy for facet joint pain found that repeated RF denervation was successful 33% to 85% of the time when the first procedure was successful. The average duration of pain relief was estimated to be 7 to 9 months after the first treatment and 11.6 months after a repeated lumbar procedure.

Alternate Methods of Denervation

Other methods with denervation include laser denervation, cryodenervation, and chemodenervation.

Laser denervation involves the use of a laser to denervate or destroy the nerves for facet joint pain. Iwatsuki et al., in 2007, reported laser denervation to the dorsal surface of the facet capsule in 21 participants who had a positive response to a diagnostic medical branch block. One year following laser denervation, 17, or 81%, of the participants had greater than 70% pain reduction. In four participants (19%) who previously had spinal surgery, the response to laser denervation was not successful. Additional controlled trials are needed to evaluate this technique.

Cryodenervation involves inserting a slim, luminated, 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.

Chemodenervation involves injections with diluted phenol solution, a chemical ablating agent that is injected into the facet joint nerve.

There is a paucity of literature on laser denervation, cryodenervation, and chemodenervation. Long-term controlled studies are lacking. Additional literature is needed to establish safety and long-term efficacy to support the use of these methods in the treatment of facet joint pain.

PROFESSIONAL SOCIETIES

Updated guidelines on interventional techniques in the management of chronic spinal pain from the American Society of Interventional Pain Physicians (ASIPP) were published in 2013. For the treatment of facet joint pain, evidence was considered good for conventional RF and limited for pulsed RF. Based on the evidence review, ASIPP recommends treatment with conventional RF neurotomy.

In 2014, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published updated guidelines on the treatment of degenerative disease of the lumbar spine. AANS/CNS indicated that lumbar medial nerve ablation is suggested for the short-term (3- to 6-month) relief of facet-mediated pain in patients who have chronic lower back pain without radiculopathy from degenerative disease of the lumbar spine (Grade B).

The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine published guidelines for chronic pain management in 2010. The guidelines stated that conventional (e.g., 80C) or thermal (e.g., 67C) radiofrequency ablation of the medial 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 provided temporary relief.
References


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Murakami E, Tanaka Y, Aizawa T, et al. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Orthop Sci. 2007;12(3):274-80.

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). 2008;33(12):1291-1297; discussion 1298.

North American Spine Society, Facet Joint Interventions - NASS Coverage Policy Recommendations, (August 2016) Burr Ridge IL, 16 pgs.

Orbegozo M, Sizer PS Jr. Facet block and denervation. In: Raj PP, ed. Textbook of Regional Anesthesia. New York, NY: Churchill Livingstone. 2003: 728-729; 959.

Patel N, Gross A, Brown L, et al. A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med. 2012;13(3):383-398.

Patel N. Twelve-Month Follow-up of a randomized trial assessing cooled radiofrequency denervation as a treatment for sacroiliac region pain. Pain Pract. Jan 7 2015.

Rambaransingh B, Stanford G, Burnham R. The effect of repeated zygapophysial joint radiofrequency neurotomy on pain, disability, and improvement duration. Pain Medicine. 2010;11(9):1343-1347.

Rupert MP, Lee M, Manchikanti L, et al. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009; 12(2):399-418.

Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine. 2004;29(21):2471-2473.

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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. 2012;4(9):686-692.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY


THE FOLLOWING CODES ARE USED TO REPRESENT NON-PULSED RADIOFREQUENCY (RF) DENERVATION: 64633, 64634, 64635, 64636

EXPERIMENTAL/INVESTIGATIONAL

THE FOLLOWING CODE IS USED TO REPRESENT RADIOFREQUENCY DENERVATION OF THE SACROILIAC JOINT: 64640



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.12 Other spondylosis with myelopathy, cervical region

M47.13 Other spondylosis with myelopathy, cervicothoracic region

M47.15 Other spondylosis with myelopathy, thoracolumbar region

M47.16 Other spondylosis with myelopathy, lumbar region

M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22 Other spondylosis with radiculopathy, cervical region

M47.23 Other spondylosis with radiculopathy, cervicothoracic region

M47.25 Other spondylosis with radiculopathy, thoracolumbar region

M47.26 Other spondylosis with radiculopathy, lumbar region

M47.27 Other spondylosis with radiculopathy, lumbosacral region

M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

M47.812 Spondylosis without myelopathy or radiculopathy, cervical region

M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.891 Other spondylosis, occipito-atlanto-axial region

M47.892 Other spondylosis, cervical region

M47.893 Other spondylosis, cervicothoracic region

M47.895 Other spondylosis, thoracolumbar region

M47.896 Other spondylosis, lumbar region

M47.897 Other spondylosis, lumbosacral region

M50.30 Other cervical disc degeneration, unspecified cervical region

M50.31 Other cervical disc degeneration, high cervical region

M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level

M50.321 Other cervical disc degeneration at C4-C5 level

M50.322 Other cervical disc degeneration at C5-C6 level

M50.323 Other cervical disc degeneration at C6-C7 level

M50.33 Other cervical disc degeneration, cervicothoracic region

M51.36 Other intervertebral disc degeneration, lumbar region

M51.37 Other intervertebral disc degeneration, lumbosacral region

M54.2 Cervicalgia

M54.5 Low back pain

M96.1 Postlaminectomy syndrome, not elsewhere classified

EXPERIMENTAL/INVESTIGATIONAL

PROCEDURE CODE 64640 IS CONSIDERED EXPERIMENTAL/INVESTIGATION WHEN REPORTED WITH THE FOLLOWING CODES

M45.7 Ankylosing spondylitis of lumbosacral region

M45.8 Ankylosing spondylitis sacral and sacrococcygeal region

M45.9 Ankylosing spondylitis of unspecified sites in spine

M46.1 Sacroiliitis, not elsewhere classified

M47.27 Other spondylosis with radiculopathy, lumbosacral region

M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

M47.897 Other spondylosis, lumbosacral region

M47.898 Other spondylosis, sacral and sacrococcygeal region

M48.07 Spinal stenosis, lumbosacral region

M48.08 Spinal stenosis, sacral and sacrococcygeal region

M48.8X9 Other specified spondylopathies, site unspecified

M51.37 Other intervertebral disc degeneration, lumbosacral region

M53.2X8 Spinal instabilities, sacral and sacrococcygeal region

M53.3 Sacrococcygeal disorders, not elsewhere classified

M53.86 Other specified dorsopathies, lumbar region

M53.87 Other specified dorsopathies, lumbosacral region

M53.88 Other specified dorsopathies, sacral and sacrococcygeal region

M54.18 Radiculopathy, sacral and sacrococcygeal region

M54.30 Sciatica, unspecified side

M54.31 Sciatica, right side

M54.32 Sciatica, left side

M54.40 Lumbago with sciatica, unspecified side

M54.41 Lumbago with sciatica, right side

M54.42 Lumbago with sciatica, left side

M54.5 Low back pain

S33.2 Dislocation of sacroiliac and sacrococcygeal joint

S33.6XXA Sprain of sacroiliac joint, initial encounter

S33.6XXD Sprain of sacroiliac joint, subsequent encounter

S33.6XXS Sprain of sacroiliac joint, sequela



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.15.09l:
01/14/2019This version of the policy will become effective on 01/14/2019.

The following change is made to the policy:
  • Consideration may be given for repeat radiofrequency (RF) treatment at least 5 months following a prior successful RF denervation when there is at least 50% reduction in pain, AND other medical necessity criteria detailed in this policy bulletin are met (i.e. following a prior successful RF denervation, if the individual’s functional status, secondary to the return of pain, seriously impedes their ability to work or to care for their activities of daily living (i.e., at least 50% reduction in pain)).

02/20/2019: In the lead-in sentence to the above criterion, "If there was a prior successful RF denervation, a minimum time of 5 months has elapsed since the prior RF treatment (per side, per anatomical level of the spine"; minium time was fixed from inadvertently typed 6 months to 5 months.

Revisions from 11.15.09k:
07/02/2018This version of the policy will become effective on 07/02/2018.

The policy has been reviewed to communicate the Company’s continuing position on Denervation of the Spinal Nerves for Chronic Pain.

ICD-10 codes have been added back to this policy bulletin.

Revisions from 11.15.09j
03/01/2018This version of the policy will become effective on 03/01/2018.
The following major changes are made to the medical necessity criteria in this medical policy:
  • Clarified the levels for cervical facet joints: at or above C2 (i.e., 2nd level vertebra)
  • A successful trial of controlled diagnostic facet joint blocks (e.g., intraarticular facet joint or medial branch block) should result in 80 percent reduction in pain.


On 02/27/2018 the following clarifications were made to the policy in Notification:
  • Non-pulsed radiofrequency (RF) denervation of the cervical facet joints at or above below C2 (i.e., 2nd level vertebra)...
  • A successful trial of controlled diagnostic facet joint blocks (e.g., intraarticular facet joint or i.e. medial branch blocks), consisting of two separate positive blocks conducted on different days with local anesthetic only (no steroids or other drugs) or a placebo-controlled series of facet joint blocks under image guidance...
  • The following statement added to the POLICY section: "For each covered spinal region (cervical or lumbar), non-pulsed radiofrequency (RF) denervation is considered medically necessary and, therefore, covered only when performed at no more than four (4) joints per session (e.g., two [2] bilateral levels or four [4] unilateral levels)."


Effective 10/05/2017 this policy has been updated to the new policy template format.




Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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