Medical Policy


Subject:Percutaneous Neurolysis for Chronic Neck and Back Pain
Policy #:  SURG.00066Current Effective Date:  01/13/2015
Status:RevisedLast Review Date:  11/13/2014

Description/Scope

This document addresses the use of percutaneous surgical procedures for the destruction of nerves (neurolysis) in individuals with chronic neck and back pain. Pulsed radiofrequency (PRF) denervation, lasers, cryodenervation, chemical neurolysis, and cooled radiofrequency denervation procedures are addressed.

Note: Please see the following related document(s) for additional information:

Position Statement

Medically Necessary: 

Initial radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3 thru C7-T1 vertebrae) or chronic lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae) is considered medically necessary when all of the following criteria are met:

  1. No prior spinal fusion surgery in the vertebral level being treated; AND
  2. Pain that is not radicular; AND
  3. Low back (lumbosacral) or neck (cervical) pain, suggesting facet joint origin when evidenced by the absence of nerve root compression is documented in the medical record on history, physical and radiographic evaluations;
    AND
  4. Pain that has failed to respond to 3 months of conservative therapy*; AND
  5. A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or injection under fluoroscopic guidance into the facet joint has resulted in at least a 50% reduction in pain for the duration of the specific local anesthetic effect used [e.g., generally 3-4 hours for bupivacaine (Marcaine®, Sensorcaine®) and 30 minutes to 1 hour for lidocaine (Xylocaine®)]. Note: a diagnostic, temporary block is not required for repeat RF at a previously treated site, if it has been less than one year since the last RF.

Repeat radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3 thru C7-T1 vertebrae) or chronic lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae) is considered medically necessary when:

  1. The above criteria have been previously met to qualify for an initial treatment; AND
  2. A minimum time of 6 months has elapsed since prior RF treatment (per side, per anatomical level of the spine).

*Note: Conservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual's specific presentation, physical findings and imaging results.

Investigational and Not Medically Necessary:

  1. Radiofrequency neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain for all uses that do not meet the criteria identified as medically necessary listed above, including but not limited to treatment of cervicogenic headache or thoracic facet pain.
  2. Chemical neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
  3. Pulsed radiofrequency denervation is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
  4. Radiofrequency neurolysis for sacroiliac (SI) joint pain is considered investigational and not medically necessary.
  5. Laser neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
  6. Cryodenervation (cryoablation) is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
  7. Cooled radiofrequency denervation is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
  8. Repeat radiofrequency neurolysis is considered investigational and not medically necessary when performed at the same anatomic site (side and spinal level) within 6 months of a prior treatment.
Rationale

Radiofrequency (RF) facet neurolysis:
van Wijk and colleagues (2005) published a multicenter, randomized controlled trial (RCT) comparing radiofrequency (RF) facet neurolysis against sham. Participants had lumbar pain for 6 months or greater with focal tenderness over the facet joints, without sensory or motor deficits or positive straight leg raising test, no indication for low back pain and a 50% or greater pain reduction 30 minutes after a diagnostic block. Of 226 participants screened, 81 were randomized to RF (n=40) or sham (n=41) lesion treatment. The visual analog score (VAS) for back pain, daily physical activities, and use of analgesics were used as outcome measures. Success was defined as at least 50% reduction of median VAS-back score without reduction in daily activities, and analgesic intake reduction of at least 25%. Participants submitted weekly diaries reporting activity, analgesic use, and pain experienced. Failures at 3 months were un-blinded and, if the participant had received sham treatment, RF was offered. Follow-up after successful treatment occurred at 6, 9 and 12 months. At 3 months, there was no difference between groups (27.5% of RF group were successes vs. 29.3% of the sham group). VAS-back score was significantly reduced in both groups These results persisted until 12 months; however, because blinding was ended at the 3-month follow-up in more than 70% of participants, a mix of additional treatments was performed between the 3- and 12-month follow-ups; some participants in both groups were lost to follow-up and outcome data collected after 3 months was difficult to interpret. However, significantly more RF individuals (62%) than sham individuals (39%) achieved > 50% pain relief on the Global Perceived Effect measured on a 4-point Likert scale.Cohen and colleagues (2008b), in a retrospective multicenter study with 262 participants, compared lumbar zygapophysial joint RF denervation success rates between at least 50% pain relief threshold versus an 80% threshold cutoff. A total of 145 participants had greater than 50% but less than 80% relief after medial branch block, and 117 obtained at least 80% relief. In the greater than 50% group, success rates were 52% and 67% on pain relief and global perceived effect (GPE), respectively, after RF. Among those who had at least 80% relief from diagnostic blocks, 56% achieved at least 50% relief from RF and 66% had a positive GPE. The authors concluded that the more stringent pain relief criteria is unlikely to improve success rates, may lead to misdiagnosis, and withholding of potentially helpful treatment.

While there is some evidence that RF facet neurolysis provides pain relief in those with chronic spine pain, many do not experience complete pain relief, and the durability of the effects remains unclear. Success rate depends on careful selection of individuals including documented reduction in pain in response to temporary block with local anesthetic of the facet nerve or injection under fluoroscopic guidance into the facet joint. In addition, the technique was most successful in those without a prior history of back surgery. There is consensus among pain management specialists that pain may reoccur and that re-treatment may be required. However, re-treatment should not occur in the same location of the spine unless a minimum time period of 6 months has elapsed since prior treatment (Schofferman, 2004). van Boxem and colleagues found "there was not sufficient evidence supporting the use of RF facet denervation for the management of cervicogenic headache (van Boxem, 2008).

Husted and colleagues (2008) reported on a retrospective study of individuals (n=20) who underwent repeat procedures after successful RF were identified. In the study, more than 80% of subjects had greater than 50% relief from repeat RF treatment and mean duration of relief from subsequent RF treatments was comparable to the initial treatment. In 2010, Rambaransingh and colleagues reported on a retrospective study of individuals (33 women and 40 men) who underwent 1st (n=73), 2nd (n=73) and 3rd (n=36) repeat RF of the same zygapophysical joint(s). Authors concluded there was no statistical significance between results for the 1st and 2nd repeat RF treatment. "Repeated cervical and lumbar RF treatment reduces pain and disability with equal effectiveness for approximately 10 months in individuals with facetogenic chronic neck and back pain."

The incidence of thoracic facet pain is significantly lower than cervical/lumbosacral facet pain and there is a paucity of evidence supporting RF facet neurolysis for thoracic facet pain, therefore, conclusions cannot be drawn as to the clinical efficacy of this application.

Cohen (2008a) published results of a randomized, single-blind, placebo-controlled, crossover clinical trial (n=28) that evaluated lateral branch radiofrequency denervation for sacroiliac joint (SI) pain. Although RF provided pain relief, the authors acknowledged the limitations of the study—size, procedure safety in multicenter locations and design. Further, based on the prevalence of SI joint pain, it is necessary to understand the pain mechanisms of SI joint pain to identify the best methods of treatment.

In a review, Muhlner (2009) found that the limited success in pain relief of the SI joint have been attributed to the inability to identify the exact innervation of the SI joint responsible for the pain. The SI joint can be innervated by the obturator or superior gluteal nerve as well as the lateral branches of the S1-S3 dorsal rami. Additionally, nerves may take circuitous routes in different people, making it difficult to find the exact location of nerves during the RF procedure.

Ayden and colleagues (2010) conducted a meta-analysis examining the effectiveness of radiofrequency ablation (RFA) of the SI joint for pain relief after an RFA procedure. Five retrospective, four prospective observational and one randomized controlled studies were found. One study used PRF and was excluded. Although each study used several outcome measures to determine a positive outcome, the main outcome measure used in the meta-analysis was a greater than or equal to 50% pain improvement, which was common in each study. Evaluations were conducted at 3, 6, 9 and 12 months. The greatest follow-up was at 3 and 6 months and served as the 2 points for which the meta-analysis was conducted. The authors used statistical applications to address proportion, heterogeneity and publication bias. At the 3 and 6 month follow-ups, half or greater of the subjects receiving RFA had a 50% pain reduction. The authors noted that the major limitation of the meta-analysis was the RFA techniques and the anatomical sites targeted for treatment. The neuroanatomy of the SI joint is diverse and the authors emphasized that accurate anatomical delineation of the joint innervation is essential for RFA needle placement. Other limitations were the lack of available literature and randomized controlled trials. The authors stated that RFA modalities need further studies to improve outcomes for those with sacroiliac joint pain.

Pulsed radiofrequency facet denervation:
Pulsed radiofrequency facet denervation has been investigated as a potentially less harmful alternative to RF facet denervation in the management of facet joint pain, however the published literature regarding pulsed radiofrequency facet denervation for chronic pain syndromes currently is insufficient to assess the efficacy of this procedure and permit scientific conclusions.

Mikeladze and colleagues (2003) reported on the treatment of lumbar or cervical spine facet joint pathology by application of PRF facet neurolysis to the medial branches of the dorsal rami at the appropriate spinal level. This retrospective study included 114 participants at a pain management clinic with clinical signs of facet joint involvement and a favorable response to a diagnostic medial branch block using local anesthetic. Mean duration of pain was 7.52 plus or minus 5.26 years. The result was regarded as successful if pain reduction was more than 50% on a visual analog scale and the duration of effect was more than 1.5 months. Of 114 individuals who had a positive response to diagnostic block, 46 did not respond favorably to PRF facet neurolysis application (pain reduction less than 50%). In 68 participants, the procedure was successful and lasted on average 3.93 plus or minus 1.86 months. Eighteen participants had the procedure repeated with the same duration of pain relief that was achieved initially. The authors concluded that the application of PRF facet neurolysis to medial branches of the dorsal rami in those with chronic facet joint arthropathy provided temporary pain relief in 68 of 118 participants. However, the authors note that, because of the relatively short duration of effect and the higher success rate with longer duration of RF facet neurolysis, PRF facet neurolysis appears less effective than the established entity.

van Zundert and colleagues (2007) conducted an RCT of 23 individuals that compared pulsed RF (n=11) to sham treatment (n=12). Success was defined as at least 50% improvement on global perceived effect (GPE), at least 20% reduction in pain on visual analogue scale and reduced pain medication use. At 3 months post treatment, 9 of 11 participants in the treatment arm and 4 of 12 in the sham arm showed at least 50% improvement on GPE. Nine of 11 participants in the treatment group and 3 of 12 participants in the sham group achieved at least 20% reduction in pain on visual analogue scale. At the 6-month follow-up, more participants in the treatment group reduced their use of pain medication, but the difference was not significant. There was a trend toward more positive outcomes in the pulsed RF group on quality of life scores. The authors concluded that pulsed RF may provide pain relief for a limited number of carefully selected individuals, but these findings must be confirmed in larger studies to determine the clinical efficacy of pulsed RF.

Chemical facet neurolysis:
The use of chemical facet injections such as phenol, alcohol and hypertonic saline has been proposed as an option for pain relief. However, there is a lack of published data to support the safety and efficacy of this technique. 

Laser facet neurolysis:
Laser facet neurolysis has been proposed for facet or sacroiliac pain. Iwatsuki (2007) reported treatment of facet syndrome by laser neurolysis in 21 study participants including 5 who had undergone previous spinal surgery. One year after laser denervation, 17 participants experienced pain reduction of at least 70%. Of the 5 individuals who had previously undergone spinal surgery, 4 did not have a successful outcome from laser denervation at 1-year follow-up. There was no control group in this study. The published literature is insufficient to support the efficacy of laser neurolysis for facet or sacroiliac joint pain.

Cooled radiofrequency denervation:
Cooling technology is a newer technology that allows for higher power delivery and larger volume of treated tissues with decreased risk of adjacent tissue damage. Cooled radiofrequency (also referred to as cooled radiofrequency ablation or cooled radiofrequency neurotomy) uses a water-cooled radiofrequency probe to ablate a larger lesion size and treat a larger area than standard RF technology. Procedures utilizing this alternative treatment include SI joint denervation and denervation of the facet joints.

In a 2010 updated guideline, the American Society of Anesthesiologists (ASA) task force on chronic pain management and the American Society of Regional Anesthesia and Pain Medicine (ASRA) state that other treatment modalities should be attempted prior to considering ablative techniques including:

Conventional radiofrequency ablation may be performed for neck pain, and water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain. Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.

Although RF for SI joint pain was a recommendation, the guideline further stated that the recommendation was equivocal and based on one clinical study. The guideline was based on scientific evidence and expert opinion.

Patel and colleagues (2012) reported results from a randomized double-blind placebo-controlled trial of lateral branch neurotomy using a cooled radiofrequency probe. The study enrolled 51 participants who demonstrated a positive response to 2 lateral branch blocks; participants were randomized in a 2:1 ratio to lateral branch radiofrequency (n=34) or sham (n=17). The primary endpoint was a comparison between the groups of the mean change from baseline in numerical rating scale (NRS) 3-month follow-up; 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 (all respectively). Treatment success was defined as a 50% or greater reduction in the numerical rating scale (NRS), at 3 months 47% of radiofrequency-treated participants and 12% of sham participants achieved treatment success. The treatment response was durable out to 9 months.

In 2013, Manchikanti and colleagues provided an updated evidence-based clinical practice guideline for interventional techniques. Authors conclude that the evidence is fair for cooled radiofrequency neurotomy for use in the treatment of sacroiliac joint.

The published literature is insufficient to support the efficacy of cooled radiofrequency denervation for chronic SIJ pain. Currently there are ongoing studies evaluating the use of cooled radiofrequency ablation for the treatment of chronic thoracic and lumbar back pain.

Cryodenervation (cryoablation):
Birkenmaier (2007) studied cryodenervation for lumbar facet pain in a small case series (n=46). At one year, 57% of the study participants achieved success or partial success. The authors cited (1) other sources of low back pain, (2) false-positive diagnostic blocks and (3) inadequate technique as possible explanations for cryodenervation failure in some of the study participants.

Background/Overview

Treatment of chronic cervical and lumbosacral pain is complex due to the subjective nature and the origin of the pain itself. Chronic cervical and lumbar facet pain is frequently attributed to disorders of the facet joint. Neck pain related to whiplash injury is also thought to be related to the cervical zygapophyseal facet joint. These pain impulses can be interrupted by blocking the nerve to the facet joint with an anesthetic injection (facet block) or coagulating the nerve with heat using a radiofrequency wave (radiofrequency neurolysis) thus preventing the neural transmission of pain. The nerve to the facet joint is sometimes referred to as the "medial branch" and therefore facet nerve block is also referred to as "medial branch" block. Typically, facet joint blocks are performed as a part of a workup for neck or low back pain. Pain relief following a precise injection of local anesthetic confirms the facet joint as the source of pain.

Radiofrequency facet (RF) neurolysis is a procedure in which sensory afferent nerve fibers are selectively destroyed with heat produced by radio waves delivered through an electrode. Treatment objectives are to eliminate pain, reduce the likelihood of recurrence and prolong the time to recurrence by selectively destroying pain fibers without inducing excessive sensory loss, motor dysfunction, or other complications.

RF facet neurolysis also has the potential risk of neuritis. Histological studies have revealed indiscriminate destruction of both small and large fibers following the RF treatment. For this reason, pulsed radiofrequency (PRF) facet neurolysis has been investigated as a treatment for chronic pain syndromes. PRF facet neurolysis is thought to be a non destructive alternative to standard RF in that it applies RF energy with a pulsed time cycle that delivers short bursts of RF current instead of a continuous RF flow. By pulsing the electrical current, the needle remains relatively cool (up to 42 degrees celsius compared to temperatures of 60-69 degrees celsius with continuous RF) so that the tissue cools slightly between each burst, reducing the risk of destroying nearby tissue and preventing any long-term damage to the nerve. It is postulated that this disrupts the transmission of impulses across small unmyelinated fibers without destroying them while larger fibers remain protected by the myelin sheath.

Chou and colleagues (2009) addressed RF for facet pain in an American Pain Society guideline and found that there was insufficient evidence to support radiofrequency facet denervation. The data from the available studies were conflicting, sparse and of lower quality.

Definitions

Ablation: The removal or destruction of a body part or tissue or its function. Ablation may be performed by surgery, hormones, drugs, radiofrequency, heat or other methods.

Cooled radiofrequency: A minimally invasive percutaneous technique that uses internally cooled radiofrequency probes (60degrees C). Radiofrequency energy is delivered from and concentrated around the electrode, generating heat in the surrounding tissue, treating a larger area than standard RF.

Dorsal rami: The posterior branches of the spinal nerves, generally smaller than the anterior branches.

Facet: Interlocking bones on the vertebrae which allow the spine to flex while maintaining its stability.

Neurolysis: The destruction of nerves or nerve tissue by heat, cutting or by chemical injection.

Non-radicular back pain: Pain which does not radiate along a dermatome (sensory distribution of a single root). Appropriate imaging does not reveal signs of spinal nerve root compression and there is no evidence of spinal nerve root compression seen on clinical exam.

Radicular back pain: Pain which radiates along a dermatome (sensory distribution of a single root) into an upper or lower extremity. Evidence of spinal nerve root compression may be seen on clinical exam and supported by appropriate imaging (generally Magnetic Resonance Imaging [MRI]) studies.

Radiofrequency: An invasive procedure that involves with an electrical current produced by radio waves in heating tissue in order to destroy it.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT 
64633Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint [when specified as radiofrequency facet neurolysis, cervical]
64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint [when specified as radiofrequency facet neurolysis, cervical]
64635Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint [when specified as radiofrequency facet neurolysis, lumbar or lumbosacral]
64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint [when specified as radiofrequency facet neurolysis, lumbar or lumbosacral]
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
03.96Percutaneous denervation of facet [when specified as radiofrequency facet neurolysis, cervical, lumbar or sacral]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after 10/01/2015]
01513ZZDestruction of cervical nerve, percutaneous approach [when specified as radiofrequency facet neurolysis]
015B3ZZDestruction of lumbar nerve, percutaneous approach [when specified as radiofrequency facet neurolysis]
015R3ZZDestruction of sacral nerve, percutaneous approach [when specified as radiofrequency facet neurolysis]
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary

CPT 
64633Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint [when specified as chemical, cooled radiofrequency, cryoablation or laser neurolysis, or thoracic neurolysis]
64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint [when specified as chemical, cooled radiofrequency, cryoablation or laser neurolysis, or thoracic neurolysis]
64635Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint [when specified as chemical, cooled radiofrequency, cryoablation or laser neurolysis, or sacral neurolysis]
64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint [when specified as chemical, cooled radiofrequency, cryoablation or laser neurolysis, or sacral neurolysis]
64999Unlisted procedure, nervous system [when specified as pulsed radiofrequency]
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
03.96Percutaneous denervation of facet [when specified as chemical, pulsed radiofrequency, cooled radiofrequency, cryoablation or laser neurolysis, or thoracic or sacral neurolysis by any method]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after 10/01/2015]
01513ZZDestruction of cervical nerve, percutaneous approach [when specified as chemical, pulsed radiofrequency, cooled radiofrequency, cryoablation or laser neurolysis]
01583ZZDestruction of thoracic nerve, percutaneous approach [when specified as facet destruction, any method]
015B3ZZDestruction of lumbar nerve, percutaneous approach [when specified as chemical, pulsed radiofrequency, cooled radiofrequency, cryoablation or laser neurolysis]
015R3ZZDestruction of sacral nerve, percutaneous approach [when specified as chemical, pulsed radiofrequency, cooled radiofrequency, cryoablation or laser neurolysis]
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses

And for the following procedure and diagnosis codes when used to describe a procedure indicated in the Position Statement section as investigational and not medically necessary

CPT 
64640Destruction by neurolytic agent; other peripheral nerve or branch
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
04.2Destruction of cranial and peripheral nerves
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
338.4Chronic pain syndrome
719.45Pain in joint (arthralgia), pelvic region and thigh
719.48Pain in joint (arthralgia), other specified site
720.2Sacroiliitis, not elsewhere classified
721.3Lumbosacral spondylosis without myelopathy
721.42Spondylosis with myelopathy, lumbar region
722.52Degeneration of lumbar or lumbosacral intervertebral disc
722.73Intervertebral disc disorder with myelopathy, lumbar region
722.83Post-laminectomy syndrome, lumbar region
724.00-724.9Other and unspecified disorders of back
729.2Neuralgia, neuritis, and radiculitis, unspecified
  
ICD-10 Procedure[For dates of service on or after 10/01/2015]
 For the following codes when specified as sacroiliac nerve destruction:
01593ZZDestruction of lumbar plexus, percutaneous approach
015A3ZZDestruction of lumbosacral plexus, percutaneous approach
015Q3ZZDestruction of sacral plexus, percutaneous approach
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
G89.4Chronic pain syndrome
M25.50Pain in unspecified joint
M25.551-M25.559Pain in hip
M46.1Sacroiliitis, not elsewhere classified
M47.18Other spondylosis with myelopathy, sacral and sacrococcygeal region
M47.28Other spondylosiswith radiculopathy, sacral and sacrococcygeal region
M47.818Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M51.07Intervertebral disc disorders with myelopathy, lumbosacral region
M51.17Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.37Other intervertebral disc degeneration, lumbosacral region
M53.3Sacrococcygeal disorders, not elsewhere classified
M53.88Other specified dorsopathies, sacral and sacrococcygeal region
M54.17-M54.18Radiculopathy, lumbosacral, sacral and sacrococcygeal region
M54.40-M54.42Lumbago with sciatica
M54.5Low back pain
  
References

Peer Reviewed Publications:

  1. Ayden SM, Gharibo CG, Mehnert M, Stitik TP. The role of radiofrequency ablation for sacroiliac joint pain: a meta-analysis. PM R. 2010; 2(9):842-851.
  2. Birkenmaier C, Veihelmann C, Trouillier H, et al. Percutaneous cryodenervation of lumbar facet joints: a prospective clinical trial. Int Orthop. 2007; 31(4):525-530.
  3. Cheng J, Pope JE, Dalton JE, et al. Comparative outcomes of cooled versus traditional radiofrequency ablation of the lateral branches for sacroiliac joint point. Clin J Pain. 2013; 29(2):132-137.
  4. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009; 34(10):1078-1093.
  5. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg. 2005; 101(5):1440-1453.
  6. Cohen SP, Hurley R, Buckenmaier CC 3rd, et al. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008a; 109(2):279-288.
  7. Cohen SP, Raja SN. Pathogenesis, diagnosis and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007; 106(3):591-614.
  8. Cohen SP, Stojanovic MP, Crooks M, et al. Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J. 2008b; 8(3):498-504.
  9. Ferrante FM, King LF, Roche EA, et al. Radiofrequency sacroiliac joint denervation for sacroiliac syndrome. Reg Anesth Pain Med. 2001; 26(2):137-142.
  10. Geurts, J W, van Wijk RM, Stolker RJ, Groen GJ. Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials. Reg Anesth Pain Med. 2001; 26(5):394-400.
  11. Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med. 2007; 39(3):225-229.
  12. Kornick C, Kramarich SS, Lamer TJ, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004; 29(12):1352-1354.
  13. Manchikanti L, Abdi S, Atluri S, et al. An update on comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013; 16:46-283.
  14. Mikeladze G, Espinal R, Finnegan R, et al. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain. Spine J. 2003; 3(5):360-362.
  15. Muhlner S. Review article: radiofrequency neurotomy for the treatment of sacroiliac joint syndrome. Curr Rev Musculoskelet Med. 2009; 2(1):10–14.
  16. 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.
  17. Patel, N., Gross A, Brown L, Gekht G. 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.
  18. Rambaransingh, B, Stanford G, Burnham R. The effect of repeated zygapophyseal joint radiofrequency neurotomy on pain, disability and improvement duration. Pain Med. 2010; 11(9):1343-1347.
  19. Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine (Phila Pa 1976). 2004; 29(21):2471-2473.
  20. Slipman CW, Bhat AL, Gilchrist RV, et al. A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain. Spine J. 2003; 3(4):310-316.
  21. Stelzer W, Aiglesberger M, Stelzer D, Stelzer V. Use of cooled radiofrequency lateral branch neurotomy for the treatment of sacroiliac joint-mediated low back pain: a large case series. Pain Med. 2013; 14(1):29-35.
  22. Vallejo R, Benyamin RM, Kramer J, et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. 2006; 7(5):429-434.
  23. van Boxem K, van Eerd M, Brinkhuize T, et al. Radiofrequency and pulsed radiofrequency treatment of chronic pain syndromes: the available evidence. Pain Pract. 2008; 8(5):385-393.
  24. Van Wijk RM, Guerts JW, Wynne HJ, et al. Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain. 2005; 21(4):335-344.
  25. Van Zundert J, Patijn J, Kessels A, et al. Pulsed radiofrequency adjacent to the cervical root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized clinical trial. Pain. 2007; 127(1-2):173-182.

 Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010; 4(112):1-24. Available at: http://journals.lww.com/anesthesiology/fulltext/2010/04000/practice_guidelines_for_chronic_pain_management_.13.aspx. Accessed on September 22, 2014.
  2. National Institute of Neurological Disorders and Stroke (NINDS). Low back pain fact sheet. Available at: http://www.ninds.nih.gov/disorders/backpain/backpain.htm. Accessed on October 18, 2014.
Index

Chemical Neurolysis
Cooled Radiofrequency Denervation
Cryodenervation
Facet Joint Nerves
Laser Neurolysis
Pulsed Radiofrequency
Radiofrequency Neurolysis
Sacroiliac Joint
Zygapophyseal Joint Pain

Document History
StatusDateAction
Revised11/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified medically necessary statements for radiofrequency neurolysis. Reformatted investigational and not medically necessary criteria; revised radiofrequency neurolysis criteria and added statement addressing use of cooled radiofrequency denervation. Updated Description, Rationale, Background, References, Websites, and Index sections.
Revised08/14/2014MPTAC review. Medically necessary position statement clarified to indicate "initial" radiofrequency (RF) neurolysis for cervical facet pain (C2-C3 thru C7-T1 vertebrae) or lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae). Revised medically necessary criteria for "repeat" procedures. Revised investigational and not medically necessary position addressing pulsed radiofrequency "denervation". Updated Description/Scope, Rationale and Reference sections.
Revised11/14/2013MPTAC review. Clarified medically necessary position. Updated Rationale, References and Websites.
Reviewed08/08/2013MPTAC review. Updated Description, References and Websites.
Reviewed11/08/2012MPTAC review. Updated Description, Coding, Websites and References.
Reviewed11/17/2011MPTAC review. Title changed. Rationale and References updated. Updated Coding section with 01/01/2012 CPT changes; removed 64622, 64623, 64626, 64627 12/31/2011.
Revised11/18/2010MPTAC review. Criteria revised to address C2-C3 as medically necessary. Description, Rationale and References updated.
Reviewed08/19/2010Medical Policy & Technology Assessment Committee (MPTAC) review. No changes to the criteria. References updated.
Revised08/27/2009MPTAC review. Criteria clarified to address vertebral anatomy, conservative treatment and diagnostic block. Policy title changed. Rationale, background, coding and references updated.
Revised08/28/2008MPTAC review. Title changed to Percutaneous Facet Neurolysis for Chronic Back Pain. Chemical facet neurolysis added to investigational and not medically necessary section. PRF for trigeminal neuralgia criteria and information deleted and addressed in SURG.00090. Investigational and not medically necessary criteria clarified. Rationale, background and references updated.
Revised05/15/2008MPTAC review. Laser neurolysis added to investigational and not medically necessary criteria. Rationale, background and references updated.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed05/17/2007MPTAC review. Rationale, coding and references updated.
Revised12/07/2006MPTAC review. Document revised to combine MED.00071 Pulsed Radiofrequency (PRF) Treatment for Chronic Pain Syndromes with this document; radiofrequency (RF) of the sacroiliac (SI) joint addressed.  References updated. 
Revised06/08/2006MPTAC review.  Revised to include sacroiliac joint. 
Revised07/14/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.07/27/2004SURG.00052Chronic Spine Pain Treatments/Procedures (Minimally Invasive)  
WellPoint Health Networks, Inc.12/02/20043.07.05Percutaneous Radiofrequency Neurolytic Destruction of Facet Joint Nerves