General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Special Note
Unilateral procedures performed at the same level(s) on the right vs left;

• If performed within 1 month of each other are counted as one procedure
• A minimum timeframe is not required between denervation procedures
• Opposite side denervation procedures performed within 1 month of the first side do not require follow-up information to be submitted

Policy
INDICATIONS FOR PARAVERTEBRAL FACET JOINT DENERVATION (RADIOFREQUENCY NEUROLYSIS)
Facet Joint Pain ^1,2,3,4,5
For the treatment of facet-mediated pain, ALL of the following must be met:

• Lack of evidence that the primary source of pain being treated is from sacroiliac joint pain, discogenic pain, disc herniation or radiculitis
• Pain causing functional disability or average pain level of ≥ 6 on a scale of 0 to 10 related to the requested spinal region
• Duration of pain of at least 3 months
  • For radiofrequency ablation following diagnostic medial branch blocks, a positive response to at least one local anesthetic block of the facet joint nerves (medial branch blocks) with at least 70% pain relief or improved ability to function for a minimal duration at least equal to that of the local anesthetic, but with insufficient sustained relief (less than 3 months duration) documented as:
  • Continued pain, after the diagnostic relief period, causing functional disability or average pain level of ≥ 6 on a scale of 0 to 10 related to the requested spinal region.
• Failure of conservative treatment* for a minimum of six (6) weeks in the last six (6) months
  • NOTE: Failure of conservative treatment is defined as one of the following:
    • Lack of meaningful improvement after a full course of treatment; OR
    • Progression or worsening of symptoms during treatment; OR
    • Documentation of a medical reason the member is unable to participate in the treatment (Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute ‘inability to complete’ treatment)

Imaging Guidance ^2,6

• The facet joint is commonly identified under image guidance by Computed tomography (CT) or Fluoroscopy. Medial Branch Blocks are commonly identified by Fluoroscopy.

NOTE: All procedures must be performed using fluoroscopic or CT guidance

Repeat Procedures ^2,3,6
Facet joint denervation procedures may be repeated only as MEDICALLY NECESSARY. Each denervation procedure requires an authorization, and the following criteria must be met for repeat procedures:

• Positive response to prior radiofrequency denervation procedures with at least 50% pain relief or improved ability to function for at least 4 months
• The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0-10 related to the requested spinal region.
• The individual is engaged in ongoing non-operative conservative treatment* unless the medical reason this treatment cannot be done is clearly documented.
• A maximum of 2 facet denervation procedures may be performed in a 12-month period per spinal region

EXCLUSIONS
These requests are excluded from consideration under this guideline:

• Radiofrequency denervation of the sacroiliac joint and/or sacral lateral branches (S1, S2, S3)

CONTRAINDICATIONS ^4,5

• Active systemic or spinal infection
• Skin infection at the site of needle puncture

BACKGROUND
Definitions
Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck, and shoulders.

Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable.  Although clinical signs are unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting individuals for controlled local anesthetic blocks of either the medial branches or the facet joint itself. 

Interventions used in the treatment of individuals with a confirmed diagnosis of facet joint pain include medial branch nerve blocks in the lumbar, cervical, and thoracic spine; and radiofrequency neurolysis. The medial branch of the primary dorsal rami of the spinal nerves has been shown to be the primary innervations of facet joints. 

Therapeutic Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
Local anesthetic block is followed by the passage of radiofrequency current to generate heat and coagulate the target medial branch nerve. Traditional radiofrequency and cooled radiofrequency are included by this definition. Pulsed radiofrequency, cryo-ablation, or laser ablation are not included in this definition.

Radiofrequency neurolysis is a minimally invasive treatment for cervical, thoracic, and lumbar facet joint pain. It involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. The objective of radiofrequency neurolysis is to both provide relief of pain and reduce the likelihood of recurrence. 

Members of the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) have agreed that conventional or thermal radiofrequency ablation of the medial branch nerves to the facet joint should be performed for neck or low back pain. Radiofrequency neurolysis has been employed for over 30 years to treat facet joint pain. Prior to performing this procedure, shared decision-making between patient and physician must occur, and the patient must understand the procedure and its potential risks and results.

Medical Necessity
Medical necessity management for paravertebral facet interventions includes an initial evaluation including history and physical examination and a psychosocial and functional assessment. The following must also be determined ³:

• Nature of the suspected organic problem
• Non-responsiveness to conservative treatment*
• Level of pain and functional disability
• Conditions which may be contraindications to paravertebral facet injections
• Responsiveness to prior interventions

It is generally considered NOT MEDCIALLY NECESSARY to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient).

Conservative Treatment* ^2,4
Non-operative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected spinal region.  

• Active components
  • Physical therapy
  • Physician-supervised home exercise program**
  • Chiropractic care
• Inactive Modalities
  • Medications (e.g., NSAIDs, steroids, analgesics)
  • Injections (e.g., epidural steroid injection, selective nerve root block)
  • Medical Devices (e.g., TENS unit, bracing)

**Home Exercise Program (HEP)** ⁸
The following two elements are required to meet conservative therapy guidelines for HEP:

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (i.e., increased pain or inability to physically perform exercises)

References:  

1. Chen Y S, Liu B, Gu F, Sima L. Radiofrequency Denervation on Lumbar Facet Joint Pain in the Elderly: A Randomized Controlled Prospective Trial. Pain physician. 2022; 25: 569-576.

2. Cohen S P, Bhaskar A, Bhatia A, Buvanendran A, Deer T et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional anesthesia and pain medicine. 2020; 45: 424-467.

3. Manchikanti L, Kaye A D, Soin A, Albers S L, Beall D et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain physician. 2020; 23: S1-S127.

4. Sayed D, Grider J, Strand N, Hagedorn J M, Falowski S et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. Journal of pain research. 2022; 15: 3729-3832.

5. Wray J K, Dixon B, Przkora R. Radiofrequency Ablation. [Update: June 12, 2023]. StatPearls. 2023; Accessed: 09/04/2024. https://www.ncbi.nlm.nih.gov/books/NBK482387/.

6. Perolat R, Kastler A, Nicot B, Pellat J, Tahon F et al. Facet joint syndrome: from diagnosis to interventional management. Insights into imaging. 2018; 9: 773-789.

7. Washington State Health Care Authority. Health Technology Clinical Committee Coverage Topic 20140321B – Facet Neurotomy. 2014; https://www.hca.wa.gov/assets/program/052714_facet_final_findings_decision[1].pdf. [Accessed: 08/30/2024]

8. Qaseem A, Wilt T J, McLean R M, Forciea M A, Denberg T D et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine. 2017; 166: 514-530.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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