DESCRIPTION
A potential source of spinal pain is the posterior zygapophysial joint (facet, Z joint), which adjoins adjacent vertebrae and is innervated by medial branches of the dorsal spinal nerves at two levels; however, there is no single history or physical examination finding that can diagnose facet joint syndrome.
Diagnosis of facet joint pain can be made when controlled local anesthetic blocks of the medial branches of the posterior rami of the spinal nerves that supply the painful joint(s) provides relief of the target pain. In dual controlled diagnostic testing, the individual typically receives injections of anesthetics with different, predictable durations of action (comparative anesthetic blocks). Alternatively, the diagnostic testing can be done using true placebos (inactive substances) as well as the active agent in a double-blind manner. The underlying premise for these injections is that the facet joints have been shown to be the source of neck and back pain using reliable methods.
Individuals with appropriate longer-term pain relief are considered candidates for therapeutic facet injections, with or without steroid, or conventional radiofrequency ablation (RFA), also known as nonpulsed or thermal RFA or RF neurotomy. Conventional RFA involves the constant application of energy usually at 80 - 85 degrees Celcius via an image-guided needle electrode inserted through the skin (percutaneously) to the affected nerve. Higher temperatures result in larger lesions, risking the surrounding tissues.
POLICY
Facet joint injections are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Thermal radiofrequency denervation (neurotomy) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
All other methods of radiofrequency medial branch denervation for the treatment of chronic neck/back pain, including, but not limited to, the following are considered investigational:
Pulsed radiofrequency denervation
Laser denervation
Chemical (e.g., alcohol, phenol, high-concentration local anesthetics)
Cryo-denervation
Low grade thermal energy (<80 degrees Celsius)
Thermal radiofrequency neurotomy to destroy any spinal structure other than medial branch nerve is considered investigational.
Ultrasound guidance for facet joint needle placement is considered investigational.
MEDICAL APPROPRIATENESS
Diagnosis and treatment of facet joint pain is considered medically appropriate if ALL of the following are met:
Indicated for ANY ONE of the following:
Diagnostic nerve blocks when ALL of the following are met:
Nonradicular neck or back pain occurring daily
Reported pain level at least 6 on scale of 0-10
Pain causes significant functional limitations
Other sources of pain ruled out
Failure of minimum three (3) months conservative treatment (e.g., oral medications, manipulation, rest/limited activity, and/or physical therapy)
Performed under fluoroscopic imaging guidance
No more than two non-fused spine levels for each region (cervical/thoracic and lumbar) tested in one session (unilateral or bilateral)
ANY ONE of the following:
Dual (controlled) intraarticular facet joint injections when medial branch blocks cannot be performed due to anatomic restrictions
Dual (controlled) medial branch nerve block injections
Absence of ALL of the following:
Allergy to the medication to be administered
Localized infection in the region to be injected
Systemic infection
Other comorbidities that could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)
Performance of another injection for pain treatment (e.g., epidural, sacroiliac joint injection or lumbar sympathetic block and/or trigger point injections) given within three (3) days of facet joint injection
Radiculopathy, unless caused by facet joint synovial cyst in lumbar spine
Neurogenic claudication
Anticoagulation therapy
Bleeding disorder
Therapeutic facet joint (intraarticular) or medial branch injection when ALL of the following are met:
Recurrent nonradicular neck or back pain
Reported pain level at least 6 on scale of 0-10
Performed under fluoroscopic imaging guidance
Indicated for ANY ONE of the following:
For initial injection, at least 75% pain relief from baseline scores achieved from diagnostic facet joint or medial branch nerve blocks
For repeat therapeutic injection, greater than 50% improvement in pain and function for at least ten (10) weeks achieved from previous therapeutic injection
No more than two non-fused spine levels for each spinal region (cervical/thoracic or lumbar) may be treated in one session [unilateral or bilateral]
Prior history of not more than four (4) therapeutic facet joint sessions within a calendar year for each spinal region (cervical/thoracic or lumbar)
Absence of ALL of the following:
Allergy to the medication to be administered
Localized infection in the region to be injected
Systemic infection
Other comorbidities that could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)
Performance of another injection for pain treatment (e.g., epidural, sacroiliac joint injection or lumbar sympathetic block and/or trigger point injections) given within three (3) days of facet joint injection
Radiculopathy, unless caused by facet joint synovial cyst in lumbar spine
Neurogenic claudication
Anticoagulation therapy
Bleeding disorder
Thermal medial branch radiofrequency neurotomy when ALL of the following are met:
A minimum two weeks have elapsed since completion of diagnostic injections
Individual has not undergone a prior radiofrequency neurotomy at the same joint within the preceding six months
Performed to thermocoagulate medial branches of the dorsal spinal nerves
Indicated by ANY ONE of the following:
For initial neurotomy, at least 80% pain relief from baseline scores achieved from diagnostic nerve blocks
For repeat neurotomy, greater than 50% improvement in pain and function for greater than five (5) months achieved from previous neurotomy
No more than two thermal radiofrequency sessions in a calendar year for each spinal region (cervical/thoracic or lumbar)
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Controlled trials are necessary to evaluate non-conventional radiofrequency ablation (laser, chemical, low-grade thermal energy and cryo-denervation).
SOURCES
Al-Najjim, M., Shah, R., Rahuma, M., & Gabbar, O. (2018). Lumbar facet joint injection in treating low back pain: radiofrequency denervation versus SHAM procedure. Systematic review. Journal of Orthopaedics, 15, 1-8. (Level 2 evidence)
American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management. Retrieved February 21, 2017 from http://www.asahq.org/quality-and-practice-management/standards-and-guidelines.
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2017). Facet joint denervation (7.01.116). Retrieved May 4, 2018 from BlueWeb. (38 articles and/or guidelines reviewed)
Boswell, M., Manchikanti, L., Kaye, A., Bakshi, S, Gharibo, C., Gupta, S., et al. (2015). A best-evidence systematic appraisal of the diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain. Pain Physician, 18, E497-E533. (Level 1 evidence)
Lee, C.H., Chung, C.K., & Kim, C.H. (2017). The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine Journal, 17 (11), 1770-1780. Abstract retrieved May 7, 2018 from PubMed database.
Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician, 16, S49-S283. (Level 2 evidence)
Manchikanti, L., Boswell, M., Singh, V., Benyamin, R., Fellows, B., Abdi, S., et al. (2009). Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12, 699-802. (Level 2 evidence)
Manchikanti, L., Hirsch, J., Falco, F., & Boswell, M. (2016). Management of lumbar zygapophysial (facet) joint pain. World Journal of Orthopedics, 7 (5), 315-337. (Level 2 evidence)
Manchikanti, L., Kaye, A., Boswell, M., Bakshi, S., Gharibo, C., Grami, V., et al. (2015). A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician, 18 (4), E535-E582. (Level 2 evidence)
OrthoNet LLC. (2018, February). Facet joint block injection. Received from OrthoNet on April 24, 2018.
Palmetto Government Benefit Administrators. (2018, February). Local Coverage Determination (LCD): Facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy (L36471). Retrieved May 7, 2018 from www.cms.org.
Poetscher, A., gentil, A., Lenza, M., & Ferretti, M. (2014). Radiofrequency denervation for facet joint low back pain: a systematic review. Spine, 39 (14), E842-E849. Abstract retrieved February 27, 2017 from PubMed database.
Vekaria, R., Bhatt, R., Ellard, D., Henschke, N., Underwood, M., & Sandhu, H. (2016). Intra-articular facet joint injections for low back pain: a systematic review. European Spine Journal, 25 (4), 1266-1281. Abstract retrieved February 27, 2017 from PubMed database.
Watters, W., Resnick, D., Eck, J., Ghogawala, Z., Mummaneni, P., Dailey,A, et al. (2014). Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. part 13: Injection therapies, low-back pain, and lumbar fusion. Journal of Neurosurgery: Spine, 21, 79-90. (Level 2 evidence)
Winifred S. Hayes, Inc. Medical Technology Directory. (2016, December; last update search November 2017). Radiofrequency ablation for facet joint denervation for chronic low back pain. Retrieved February 20, 2017 from www.Hayesinc.com/subscribers (54 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc. Medical Technology Directory. (2016, November; last update search October 2017). Percutaneous radiofrequency ablation for cervical and thoracic spinal indications. Retrieved February 20, 2017 from www.Hayesinc.com/subscribers (45 articles and/or guidelines reviewed)
Wu, T., Zhao, W., Dong, Y., Song, H., & Li, J. (2016). Effectiveness of ultrasound-guided versus fluoroscopy or computed tomography scanning guidance in lumbar facet joint injections in adults with facet joint syndrome: a meta-analysis of controlled trials. Archives of Physical Medicine and Rehab, 97 (9), 1558-1563. Abstract retrieved February 27, 2017 from PubMed database.
ORIGINAL EFFECTIVE DATE: 4/1999
MOST RECENT REVIEW DATE: 10/24/2018
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.