Nonpulsed radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints is considered medically necessary when ALL of the following criteria are met.
No prior spinal fusion surgery in the vertebral level being treated; AND
Disabling low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical, and radiographic evaluations; and the pain is not radicular; AND
Pain has failed to respond to 3 months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; AND
There has been a successful trial of controlled medial branch blocks (see Policy Guidelines section); AND
If there has been a prior successful radiofrequency denervation, a minimum time of 6 months has elapsed since prior radiofrequency treatment (per side, per anatomic level of the spine).
Radiofrequency denervation is considered investigational for the treatment of chronic spinal or back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet joint pain.
All other methods of denervation are considered investigational for the treatment of chronic spinal or back pain, including, but not limited to pulsed radiofrequency denervation, laser denervation, chemodenervation (eg, alcohol, phenol, or high concentration local anesthetics), and cryodenervation.
Therapeutic medial branch blocks are considered investigational.
If there has been a prior successful radiofrequency denervation, additional diagnostic medial branch blocks for the same level of the spine are investigational.
