HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-150-014
Topic:
Radiofrequency Joint Ablation-Denervation
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Radiofrequency joint denervation/ablation (i.e., facet neurotomy, facet rhizotomy) refers to the insertion of a radiofrequency probe towards the medial branch of the posterior primary rami, which supplies the innervation to the facet joints under fluoroscopic guidance. The radiofrequency electrode is then utilized to create a “continuous” heat lesion by coagulating the nerve supplying the joint with the intention of providing pain relief by denervating the painful facet joint. The injection/block applies directly to the facet joint(s) blocked/ablated and not to the number of nerves blocked/ablated that innervate the facet joint(s).

 

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

A radiofrequency joint denervation/ablation may be considered medically necessary for ANY of the following indications:

  • For facet mediated pain resulting from disease, injury or surgery when the following criteria are met:
    • Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation): and
    • Failure of at least three (3) months of conservative therapy (e.g., exercise, physical methods including physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs (NSAID’s and/or analgesics) unless contraindicated and the reason(s) for the contraindication(s) is/are documented in the medical record; and
    • Two positive diagnostic facet joint injections/medial branch blocks using a local anesthetic as evidenced by 80% pain relief for the duration of the local anesthetic used.           
  • For an individual with a spinal fusion and facet mediated pain resulting from disease, injury, or surgery, when the procedure is performed at an unfused spinal segment located either above or below the fused spinal segment, and the following criteria are met:
    • Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculopathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation); and
    • Failure of at least three (3) months of conservative therapy (e.g., exercise, physical methods including physical therapy, chiropractic care, NSAID’s and/or analgesics) unless contraindicated and the reason(s) for the contraindication(s) is/are documented in the medical record; and
    • Two positive diagnostic facet joint injections/medial branch blocks using a local anesthetic as evidenced by 80% pain relief for the duration of the local anesthetic used.
  • A repeat radiofrequency joint denervation/ablation when BOTH of the following criteria are met:
    • There is documented pain relief of at least 50% which has lasted for a minimum of 12 weeks; and
    • The procedure is performed at a minimum of six (6) months following the prior denervation/ablation

 

Performance of a radiofrequency joint denervation/ablation for ANY of the following indications is considered not medically necessary:

  • When performed without the use of fluoroscopic guidance; or
  • Performing more than two (2) procedures at the same level(s) during a twelve (12) month period of time; or
  • In the absence of two (2) sequential positive diagnostic facet joint injections/medial branch blocks; or
  • When performed for neck pain or low back pain in the presence of an untreated radiculopathy; or
  • When performed at a posteriorly fused spinal motion segment; or
  • When performed on more than three (3) levels during the same session/procedure; or
  • When performed to treat pain arising from above C2-3 and below L5-S1 spinal levels.

 

Performance of radiofrequency joint denervation/ablations for ANY of the following indications is considered experimental/investigational and therefore non-covered because the safety and and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

  • Pulsed radiofrequency ablation for chronic pain syndromes; or
  • Endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy; or
  • Cryoablation/cryoneurolysis/cryodenervation; or
  • Chemical ablation (e.g., alcohol, phenol, glycerol); or
  • Laser ablation; or
  • Ablation by any method for sacroiliac (SI) joint pain; or
  • Cooled radiofrequency ablation.

 

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Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Radiofrequency Facet Denervation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.