Title: Facet Joint Denervation (Cervical and Lumbar)
POLICY Current Effective Date: April 30, 2015
A. Thermal radiofrequency denervation of cervical facet joints (C 2-3 and below) and lumbar facet joints is considered medically necessary when ALL of the following criteria are met:
- No prior posterior spinal fusion surgery in the vertebral level being treated AND
- Disabling low back (lumbosacral) or neck (cervical) pain, suggestive of intrinsic facet joint origin as supported by history and physical AND
- Pain has failed to respond to three (3) months of conservative management. AND
- There has been a successful trial of confirming medial branch blocks (See Policy Guidelines) AND
- If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six (6) months has elapsed since prior RF nerve treatment.
B. Radiofrequency denervation is considered experimental / investigational for the treatment of chronic spinal / back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet joint pain.
C. All other methods of denervation are considered experimental / investigational for the treatment of chronic spinal / back pain, including, but not limited to pulsed radiofrequency denervation, laser denervation, chemodenervation (e.g., alcohol, phenol, or high-concentration local anesthetics), and cryodenervation.
D. Therapeutic medial branch blocks are considered experimental / investigational.
E. If there has been a prior successful radiofrequency (RF) denervation, additional diagnostic medial branch blocks for the same level of the spine are not medically necessary.
Policy Guidelines
A successful trial of controlled diagnostic medial branch blocks consists of:
- 2 separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or
- a placebo controlled series of dual confirming blocks, under fluoroscopic guidance, that has resulted in at least an 80% reduction in pain for the duration of the local anesthetic used (e.g., 3 hours longer with bupivacaine than lidocaine).
No therapeutic intra-articular injections (i.e., steroids, saline, or other substances) should be administered for a period of at least 4 weeks prior to the diagnostic medial branch block. The diagnostic blocks should involve the levels being considered for RF treatment and should not be conducted under intravenous sedation unless specifically indicated (e.g., the patient is unable to cooperate with the procedure). These diagnostic blocks should be targeted to the likely pain generator. Single level blocks lead to more precise diagnostic information, but multiple single level blocks require several visits and additional exposure to radiation.
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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