CurrentPremera BluecrossPolicy 7.01.555

MEDICAL POLICY 7.01.555 Facet Joint Denervation

Defines medical necessity, investigational uses, documentation and coding for percutaneous non-pulsed radiofrequency denervation of cervical (C2-3 and below), thoracic, and lumbar facet joints for chronic facet-mediated spinal pain. Also specifies investigational status for other denervation methods and therapeutic medial branch blocks.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 7.01.555 Facet Joint Denervation

Policy CodePolicy 7.01.555

Change TypeAnnual review; clarifications; interim revisions

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionNon-pulsed radiofrequency denervation must be pre-approved by the plan and submit required documentation as outlined in Documentation Requirements.

POLICY UPDATE CHANGES

Policy updated with literature review through October 6, 2024; no references added. Policy statements unchanged.

Clarified that imaging from the last 12 months showing absence of disc herniation or narrowing of the vertebral canal should be used to confirm other causes of pain have been ruled out.

Changed radiofrequency denervation to thoracic facet joints from investigational to medically necessary when criteria met.

3Anatomic regions covered (cervical, thoracic, lumbar)

2Required diagnostic medial branch blocks

80%Minimum pain relief threshold for blocks

6 months

Minimum interval after prior RF before repeat

Coverage Summary

Policy number 7.01.555 (Payer: Blue Cross Blue Shield) defines coverage for percutaneous non-pulsed radiofrequency denervation of facet (zygapophyseal) joints. The policy scope covers cervical (C2-3 and below), thoracic, and lumbar facet joint denervation and specifies both medical necessity criteria and investigational uses. The policy is effective Feb. 1, 2025 and was last reviewed on Jan. 13, 2025. The overall coverage stance is mixed: non-pulsed RF denervation is considered medically necessary when all criteria are met, while other denervation methods are considered investigational.

Quick facts and thresholds

Duration of pain> 3 months

Required diagnostic MBBs2 separate positive blocks on different days

Diagnostic MBB pain relief threshold>= 80% pain relief for duration of anesthetic

Imaging recency to exclude other causesRadiographic imaging within the last 12 months

Minimum interval after prior RF>= 6 months (per side, per vertebral level)

Anatomic regions coveredCervical (C2-3 and below), Thoracic, Lumbar (3)

Medical Necessity Criteria

Non-pulsed radiofrequency denervation - Medical Necessity

Non-pulsed radiofrequency denervation of cervical (C2-3 and below), thoracic, and lumbar facet joints is considered medically necessary when ALL of the following criteria are met:

ALL of the following

There is no prior spinal fusion surgery in the vertebral level being treated
must document absence of spinal fusion at specific vertebral level
Individual has experienced disabling low back (lumbosacral), thoracic, or neck (cervical) pain for greater than three (3) months suggestive of facet joint origin> 3 months
detailed history and physical required
Other causes of cervical, thoracic, or lumbar pain such as disc herniation or narrowing of the vertebral canal have been excluded as documented in the medical record and radiographic imaging performed within the last 12 months

Investigational / Not Medically Necessary

The following are considered investigational for treatment of chronic spinal/back pain:

ANY of the following

Radiofrequency denervation uses that do not meet the above medical necessity criteria
Therapeutic medial branch blocks (therapeutic MBBs)
All other methods of facet denervation, including but not limited to pulsed radiofrequency denervation, laser denervation, chemodenervation (alcohol, phenol, or high-concentration local anesthetics), cryodenervation, cooled radiofrequency ablation (COOLIEF), and endoscopic radiofrequency denervation

(Operational note) Requests for pulsed RF, laser, chemodenervation (alcohol/phenol), cryodenervation, cooled RF (COOLIEF), endoscopic RF denervation, and therapeutic medial branch blocks are investigational and will be denied

Coding

Covered CPT codes (procedures for destruction by neurolytic agent / RF denervation)CPTCovered

64633	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (CT or fluoroscopy); cervical or thoracic, single facet joint
64634	Destruction by neurolytic agent; paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic; each additional facet joint (List separately in addition to code for primary procedure)
64635	Destruction by neurolytic agent; paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Unlisted CPTCPT

64999

Unlisted procedure; nervous system

Prior Authorization

Pre-approval required

Non-pulsed radiofrequency denervation must be pre-approved by the plan before it is covered; submit required documentation as outlined in Documentation Requirements.

64633
64634
64635
64636

Provider Actions & Documentation Requirements

Documentation Required

Documentation to support medical necessity

Provide level and side to be treated; documentation that no spinal fusion at treated level; detailed history and physical; imaging from last 12 months showing absence of disc herniation or narrowing of the vertebral canal; records of >=3 months conservative therapy failure; documentation of two separate positive diagnostic medial branch blocks with >=80% relief for duration of anesthetic.

Level and side to be treated
Confirmation that no spinal fusion surgery was performed at the vertebral level being treated
Detailed history and physical documenting duration and characteristics of disabling pain
Copy of imaging from the last 12 months showing absence of disc herniation or narrowing of the vertebral canal
Records showing failure of at least 3 months of conservative therapy
Documentation of two separate positive diagnostic medial branch blocks on different days with local anesthetic only, each producing >=80% pain relief for the duration of the anesthetic

Background

Facet (zygapophyseal) pain can be difficult to diagnose; response to controlled medial branch blocks (MBBs) is used diagnostically to identify individuals likely to benefit from denervation. Non-pulsed thermal radiofrequency denervation produces thermal lesions to destroy medial branch nerves and can provide temporary pain relief, although the nerves often regenerate and repeat procedures may be required. Alternative denervation methods (including pulsed radiofrequency, laser, chemical denervation with alcohol or phenol, cryodenervation, cooled radiofrequency ablation, and endoscopic radiofrequency) have limited or insufficient evidence and are considered investigational.

Key definitions

Diagnosis of facet-mediated painRequires establishment of pain relief following dual medial branch blocks performed at different sessions.

Facet jointsJoints connecting vertebrae; each is innervated by two medial branch nerves.

SessionAll injections/blocks/RF procedures performed on one day.

RegionAll injections performed in cervical/thoracic, or all injections performed in lumbar (not sacral) spinal areas.

Evidence & Rationale

Evidence summary

Evidence sufficiency for non-pulsed RFSufficient to determine improvement in net health outcome for carefully selected individuals.

Evidence for pulsed RF and other methodsInsufficient to determine efficacy; considered investigational.

Medicare Determinations

Medicare determinations: No national coverage determination.

Revision History

05/12/14revised

New policy replacing 7.01.116; non-pulsed RF considered medically necessary for level C2-3 (changed from investigational at C2) when criteria met, including two controlled medial branch blocks.

05/27/15clarified

Annual review updated with literature through March 2015; definition of terms added; policy statements unchanged.

02/16/16clarified

Coding update; unlisted CPT 64999 added.

Policy Summary

PayerPremera Bluecross

PolicyMEDICAL POLICY 7.01.555 Facet Joint Denervation

Policy CodePolicy 7.01.555

Change TypeAnnual review; clarifications; interim revisions

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionNon-pulsed radiofrequency denervation must be pre-approved by the plan and submit required documentation as outlined in Documentation Requirements.

On This Page

imaging within last 12 months

copy of imaging demonstrating absence of disc herniation or canal narrowing required

Pain has failed to respond to three (3) months of conservative management>= 3 months

conservative management may include oral analgesics (NSAIDs, acetaminophen), manipulation or physical therapy, or a home exercise program

Diagnostic medial branch blocks

There has been a successful trial of controlled medial branch blocks (MBBs) consisting of 2 separate positive blocks on different days with local anesthetic only (no steroid or other drugs)
blocks must be on different days and use local anesthetic only
Each medial branch block resulted in at least 80% pain relief for the duration of the anesthetic used>= 80% pain relief
blocks must involve the vertebral levels being considered for treatment

Prior RF

If there has been a prior successful radiofrequency denervation, a minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine)>= 6 months (per side, per vertebral level)
progress note supporting prior response required
If there has been a prior successful radiofrequency denervation, additional diagnostic medial branch blocks for the same level of the spine are not medically necessary
statement of not medically necessary for repeat diagnostic MBBs after prior successful RF

(Operational note) Non-pulsed radiofrequency denervation must be pre-approved by the plan and documentation per policy required

See Documentation Requirements for required records

See Documentation Requirements and Denial Risk

Denial Risk

Investigational procedures not covered

Requests for pulsed RF, laser, chemodenervation (alcohol/phenol), cryodenervation, cooled RF (COOLIEF), endoscopic RF denervation, and therapeutic medial branch blocks are investigational and will be denied.

Pulsed radiofrequency denervation
Laser denervation
Chemodenervation (alcohol, phenol, or high-concentration local anesthetics)
Cryodenervation
Cooled radiofrequency ablation (COOLIEF)
Endoscopic radiofrequency denervation
Therapeutic medial branch blocks (therapeutic MBBs)

Prior Authorization

Pre-approval required

Non-pulsed radiofrequency denervation must be pre-approved by the plan before it is covered. See Documentation Requirements for the supporting clinical records that must be submitted with a prior authorization request.

11/01/16clarified

Annual review approved October 11, 2016; literature updated; statements unchanged.

12/01/17clarified

Annual review updated with literature through October 2017; clarified criteria for facet joint origin; CPT 64999 removed.

03/01/18clarified

Minor update added Documentation Requirements section.

07/01/18clarified

Interim review added cooled radiofrequency ablation to investigational denervation methods.

02/01/19clarified

Annual review updated with literature through September 2018; policy statements unchanged.

08/01/19clarified

Interim review added endoscopic radiofrequency ablation/rhizotomy to investigational denervation methods and added CPT 64999.

02/01/20clarified

Annual review updated with literature through September 2019; policy statements unchanged.

04/01/20revised

Policy scheduled for deletion and replacement with InterQual criteria effective July 2, 2020 (later reversed).

06/10/20clarified

Interim review reinstated the policy and cancelled deletion; effective June 10, 2020.

02/01/21clarified

Annual review updated with literature through September 18, 2020; references added; statements unchanged.

02/01/22clarified

Annual review updated with literature through September 29, 2021; references added; statements unchanged.

08/01/22revised

Interim review approved July 12, 2022: changed radiofrequency denervation for thoracic facet joints from investigational to medically necessary when criteria are met.

08/23/22clarified

Minor clarifying edit removing parenthetical word 'rhizotomy' from endoscopic RF denervation bullet and minor procedure wording edits to align with thoracic policy criteria.

02/01/23clarified

Annual review updated with literature through September 30, 2022; references added; minor editorial refinements; changed wording 'patient' to 'individual'.

06/14/23clarified

Policy correction removing documentation requirement that diagnostic MBBs should not be conducted under IV sedation.

02/01/24clarified

Annual review updated with literature through September 14, 2023; references added; minor clarifying edits regarding medial branch blocks; statements unchanged.

09/01/24clarified

Interim review approved August 13, 2024: clarified that imaging from the last 12 months showing absence of disc herniation or canal narrowing should be used to document exclusion of other causes of pain.

01/13/25clarifiedLatest

Annual review approved January 13, 2025: policy updated with literature review through October 6, 2024; no references added; policy statements unchanged.