Radiofrequency ablative (RFA) procedures for chronic facet-mediated neck, back and sacroiliac joint pain These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Radiofrequency ablative denervation procedures of the cervical, thoracic and lumbar spine require prior authorization.

Diagnostic medial branch block (MBB) does not require prior authorization.

Prior authorization is not applicable for radiofrequency for the treatment of sacroiliac joint pain. The provider and facility will be liable for payment unless: • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and • The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

Indications that are covered

Radiofrequency ablative denervation (RFA) is covered when the following criteria are met:

1. Initial RFA is covered to treat axial (non-radicular) neck and back pain if all of the following criteria are met: A. Severe pain limiting activities of daily living for at least 3 months despite conservative treatments (such as exercise, activity modification or chiropractic care). Documentation of conservative treatments must correspond to the current episode of pain (within 6 months). o Conservative treatments must include physical therapy (PT), at least 4 visits over a course of 6 weeks or less. Active muscle conditioning is required as part of physical therapy. o Physical therapist’s notes must be submitted, or there must be a physician’s statement in the clinical documents that explains why physical therapy is contraindicated. o If a member is unable to complete physical therapy due to progressively worsening pain and disability, documentation in the physical therapists notes demonstrating this is required. o The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. and B. Skeletal and neuro imaging studies confirm that the principal cause of the pain intended to be treated with RFA is not disc herniation, spinal instability, fracture, malignancy, or spinal stenosis C. Two trials of diagnostic medial branch block injections must be received as described below:, i. The first trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain ii. The second trial of diagnostic medial branch block (MBB) injection relieves at least 70% of the pain iii. The first and second MBB injections were performed under fluoroscopic guidance iv. The first and second MBB injections were performed on different days within the 6 months previous to the RFA procedure.*note: Intra-articular injections of the paravertebral facet (zygapophyseal) joint are not considered diagnostic for the purposes of assessing suitability for RFA 2. RFA treatment procedure is limited to 3 levels per side of each spinal region (cervical, thoracic or lumbar) in a 6 month period (prior authorization form requires identification of the level and side). Three levels is defined as three (3) punctures (innervates two facet joints), each of which lesions one medial branch of the dorsal ramus nerve; (Example: one unit of 64633 plus two units of 64634 equals three levels), or for a bilateral procedure, three pairs of punctures. (For bilateral RFA, the modifier 50 should be used.) 3. Repeat Radiofrequency ablative denervation (RFA) at the same level is covered when the following criteria are met:

Page 1 of 4 A. A minimum of six months has elapsed since the initial RFA; B. The initial RFA relieved at least 50% of the pain within 3 months of the procedure date as reported by the patient; C. Severe pain limiting activities of daily living for at least 3 months despite conservative treatments (such as exercise, activity modification or chiropractic care). Documentation of conservative treatments must correspond to the current episode of pain (within 6 months). o Conservative treatments must include physical therapy (PT), at least 4 visits over a course of 6 weeks or less. Active muscle conditioning is required as part of physical therapy. o Physical therapist’s notes must be submitted, or there must be a physician’s statement in the clinical documents that explains why physical therapy is contraindicated. o If a member is unable to complete physical therapy due to progressively worsening pain and disability, documentation in the physical therapists notes demonstrating this is required. o The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons.

Indications that are not covered

The following (RFA) procedures are considered experimental and investigational and not covered:

1. Radiofrequency Ablation (RFA), conventional, cooled or pulsed, for treatment of sacroiliac joint pain. This includes treatment of the sacroiliac joint and the nerves innervating the sacroiliac joint. 2. Pulsed Radiofrequency Ablation (RFA) for treatment of facet-mediated pain (64999) 3. Cooled Radiofrequency Ablation (RFA) for treatment of facet-medicated pain (64999) 4. Laser radiofrequency ablation/denervation/rhizotomy procedures 5. Endoscopic radiofrequency ablation/denervation/rhizotomy procedures

Definitions

Radiofrequency ablative denervation (also known as percutaneous radiofrequency ablation, facet neurotomy, facet rhizotomy, or articular rhizolysis) - an invasive procedure in which radiofrequency energy is applied via a percutaneous probe inserted toward the medial branch nerve supplying a facet (zygapophysial) joint. i The probe creates a heat lesion, coagulating the nerve and denervating a painful facet joint.

Diagnostic medial branch block (MBB) - an invasive procedure in which a drug (e.g. or bupivacaine), is injected in close proximity to the medial branch of the dorsal ramus that supplies a facet (zygapophysial) joint. The intent is to provide temporary relief of pain and serve as a diagnostic test to localize facetogenic pain, so as to guide possible future radiofrequency denervation. The injection is NOT intra-articular (into the joint).

Codes

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Radiofrequency Ablation Codes that require prior authorization: Codes Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 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) 64999 Unlisted procedure, nervous system, when used to represent pulsed RFA or cooled RFA for treatment of facet mediated cervical, thoracic or lumbar pain, or sacroiliac joint pain

Page 2 of 4 Prior authorization does not apply to the following non-covered code: Code Description 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography

Diagnostic medial branch block (MBB) codes: Codes Description 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Approved Medical Director Committee 3/14/05; Revised 8/8/06, 12/6/07, 10/26/09, 1/26/10; 2/1/10, 8/27/10, 8/18/11, 12/02/11,1/26/12, 6/07/2012, 3/15/13, 1/10/2014, 07/29/2014, 6/21/2016, 1/6/2017, 1/22/19, 8/6/2019, 2/7/2020 Annual Review 8/8/06, 12/6/07, 7/1/08, 10/26/09, 8/27/10; 8/2011, 12/2011, 1/2012, 1/2013, 3/15/13, 1/2014, 7/2014, 7/2015, 1/2016, 1/2017, 1/2018,1/2019, 1/2020, 1/2021

References

1. Aydin, S., Gharibo, C., Mehnert, M., Stitik, T., (2010) The Role of Radiofrequency Ablation for Sacroiliac Joint Pain: A Meta- Analysis, PM &R, Volume 2, Issue 9 Pages 842-851 2. Cohen,S, Doshi, T., Constatineescu, , O., Zhao, Z., Kurihara, C., larkin, T., Pasquina, P. (2018) Effectiveness of Lumbar Facet Joints and Predictive Value before Radiofrequency Denervation The Facet Treatment Study (FACTS), a Randomized Controlled Clinical Trial, Anesthesiology V 129: 517-35 3. Cohen, S. P., Williams, K. A., Kurihara, C., Nguyen, C., Shields, C., Kim, P., … Strassels, S. A. (2010). Multicenter, Randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic Medial branch (facet joint nerve) block treatment paradigms before lumbar facet Radiofrequency Denervation. Anesthesiology, 113(2), 395–405. 4. Cohen, S. P., Strassels, S. A., Kurihara, C., Crooks, M. T., Erdek, M. A., Forsythe, A., & Marcuson, M. (2009). Outcome predictors for Sacroiliac joint (lateral branch) Radiofrequency Denervation.Regional Anesthesia and Pain , 34(3), 206–214. 1. 5. Cohen, SP, Hurley, RW, Buckenmaier, CC, III, Kurihara, C, Morlando, B, and Dragovich, A. Randomized placebo- controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology. 2008;109(2):279-288 6. Desai, M. (2015) Thoracic radiofrequency ablation, Techniques in Regional Anesthesia and Pain Management, 2015-07- 01, Volume 19, Issue 3, pages 126-130. 7. ECRI Institute. Cooled Radiofrequency Nerve Ablation for Treating Sacroiliac Joint Pain. Plymouth Meeting (PA): ECRI Institute; 2014 Oct 28. (Custom Rapid Review). 8. ECRI Institute. (2012). Radiofrequency Denervation for treating chronic low-back pain. Plymouth Meeting, PA: ECRI Institute. 9. *ECRI Institute. Radiofrequency Denervation for Treating Low-back Pain. Plymouth Meeting (PA): ECRI Institute; 2015 Dec 28. (Custom Rapid Review).

Page 3 of 4 10. Hambraeus, J,, Hambraeus, K, Persson, J. (2018) Radiofrequency Denervation Improves Health-Related Quality of Life in Patients with Thoracic Zygapophyseal Joint Pain, Pain Medicine, Volume 19, Issue 5, May 2018 pg. 914-919 11. Hayes, Inc. Hayes Technology Brief. Cooled Radiofrequency Denervation of the Sacroiliac Joint (Pain Management SInergy System, Baylis Medical Co. Inc.) for Treatment of Chronic Low Back Pain. August, 2011, Archived August 2012. 12. Hayes, Inc. Hayes Search and Summary, Laser Facet Thermal Ablation for Treatment of Low Back Pain. Lansdale, PA: Hayes, Inc. January 2013 13. Hayes, Inc. Hayes Medical Technology Directory Report. Percutaneous Radiofrequency Ablation for Cervical and Thoracic Spinal Indications. Lansdale, PA: Hayes, Inc.; November, 2016, Reviewed January 2020 14. Hayes, Inc. Hayes Health Technology Assessment. . Pulsed Radiofrequency Application to the Dorsal Root Ganglion for Treatment of Cervical Radicular Pain Lansdale, PA: Hayes, Inc.; May 2019, Reviewed August 2020 15. Hayes, Inc. Hayes Medical Technology Assessment. Pulsed Radiofrequency Application to the Dorsal Root Ganglion for Treatment of Lumbosacral Radicular Pain Lansdale, PA: Hayes, Inc.; May 2019., Reviewed September 2020 16. Hayes, Inc. Evidence Analysis Research Brief. Pulsed Radiofrequency Treatment of Complex Regional Pain Syndrome of the Lumbar Region. Lansdale, PA: Hayes, Inc.; October 2020 17. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Facet Joint Denervation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; December, 2016, Reviewed March 2020 18. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; May, 2007. Reviewed July, 2011. Archived, April, 2012. 19. Hayes Inc. Hayes Medical Technology Directory Report. Radiofrequency Ablation for Sacroiliac Joint Denervation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc. February 2017, Reviewed .May 2020 20. Hayes, Inc. Hayes Medical Technology Directory Report. Radiofrequency ablation for sacroiliac joint pain. Lansdale, PA: Hayes, Inc.; August, 2012. Reviewed May, 2016. 21. Helm S, Hayek SM, Benyamin RM, Manchikanti L. (2009) Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician. Jan-Feb;12(1):207-32, 22. ICSI, Pain: Assessment, Non-Opiod Treatment Approaches and Opiod Management, (Revised, 2017) Institute for Clinical Systems Improvement (ICSI) Guideline/ Eighth Edition, Version 2. 23. Isaac, Z. Management of non-radicular neck pain. In: UpToDate, Atlas, S. (Ed), UpToDate, Waltham, MA. (Accessed on December 16, 2020) 24. Kapural L, Ng A, Dalton J, Mascha E, Kapural M, de la Garza M, Mekhail N. (2008). Intervertebral disc biacuplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med Jan-Feb 9 60-7. 25. Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R. M., Boswell, M. V., Buenaventura, R. M., . Hirsch, J. A. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician, 16(2 Suppl). 26. Manchikanti KN, Atluri S, Singh V, Geffert S, Sehgal N, Falco FJ. An update of evaluation of therapeutic thoracic facet joint interventions. (2012). Pain Physician 15(4): E463-E481 27. Washington State Health Care Authority. Health Technology Assessment. Facet Neurotomy May 2014. 28. Yeung, A., Gore, S. (2014). Endoscopically guided foraminal and dorsal rhizotomy for chronic axial back pain based on cadaver and endoscopically visualized anatomic study. International journal of spine surgery, 8.

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