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| LCD Information |
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| LCD ID Number back to top |
| L26593 |
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| LCD Title back to top |
| Paravertebral Facet Joint/Nerve Denervation |
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| Contractor's Determination Number back to top |
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| AMA CPT / ADA CDT Copyright Statement back to top |
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CPT codes, descriptions and other data only are copyright
2009 American Medical Association (or such other date of publication of CPT).
All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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| CMS National Coverage Policy back to top |
Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
CMS Manual System. Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, §80 describes carrier coverage for physician supervision of diagnostic x-ray, lab and other diagnostic tests.
CMS Manual System. Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.3 states that acupuncture is not considered a reasonable and necessary service and will not be reimbursed for Medicare beneficiaries.
CMS Manual System. Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.7 states that prolotherapy is not considered a reasonable and necessary service and will not be reimbursed for Medicare beneficiaries.
CMS Manual System. Publication 100-4, Medicare Claims Processing Manual, Chapter 12, §40 describes carrier payment rules for “Surgeons and Global Surgery.”
CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Section 160.1
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| Primary Geographic Jurisdiction back to top |
Maine
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| Oversight Region back to top |
Region I
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| Original Determination Effective Date back to top |
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For services performed on or after
05/16/2008
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| Original Determination Ending Date back to top |
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| Revision Effective Date back to top |
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For services performed on or after
06/01/2009
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| Revision Ending Date back to top |
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| Indications and Limitations of Coverage and/or Medical Necessity back to top |
ABSTRACT
Paravertebral facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain, 54% to 60% of patients with neck pain, and 42% to 48% of patients with thoracic pain (Boswell et al, 2005, pp.5). Facet joint arthropathy (joint disease) is generally diagnosed through a double-comparative local anesthetic blockade of a joint, either by intra-articular injection of a small volume of local anesthetic (0.5 to 1.0 ml), or blockade of the medial branch nerves of the dorsal rami innervating the joint with a small volume of local anesthetic.
Facet joint denervation may be considered if double-comparative paravertebral facet joint/nerve blocks do provide significant pain relief, but the pain relief is not long-lasting (single diagnostic blocks are acceptable in anticoagulated patients requiring anticoagulation reversal). Paravertebral facet joint denervation is the destruction of a paravertebral facet joint nerve by neurolytic agent (e.g., chemical, thermal, electrical, radiofrequency). This procedure involves placing a needle or radiofrequency cannula adjacent to each of the two, or more, medial branch nerves innervating the target joint.
INDICATIONS AND LIMITATIONS
The decision to treat chronic pain by invasive or destructive procedures must be based on a thorough evaluation of the patient and include a systematic assessment of the location, intensity, and pathophysiology of the pain. A detailed pain history that includes prior treatment and response to treatment is essential. A detailed physical examination and review of all pertinent diagnostic tests is also needed.
For those beneficiaries that are considered candidates for denervation, the medical record should reflect the failure of conservative therapy and that appropriate diagnostic paravertebral facet joint/nerve block studies have been performed. Studies should document the specific joint level affected and that significant, but not long-lasting, pain relief has been obtained from the paravertebral facet joint/nerve blocks. Significant pain relief is defined as greater than or equal to ≥50% initially with the ability to perform previously painful maneuvers, and persistent pain relief is defined as a minimum of six (6) weeks of ≥50% relief with the continued ability to perform previously painful maneuvers. (Please see the Local Coverage Determination (LCD) Paravertebral Facet Joint/Nerve Blocks - Diagnostic and Therapeutic [L26591]).
Paravertebral Facet Joint Denervation is appropriate for the following when substantiated by the results of previous diagnostic and therapeutic paravertebral facet joint blockade: - Hypertrophic arthropathy of the facet joints causing back and/or neck pain;
- Back or neck pain following whiplash/post-traumatic injury;
- Back pain greater than leg pain;
- Neck pain greater than arm pain;
- Back or neck pain associated with suspected motion segment instability/hypermobility or pseudoarthrosis following fusion; or
- Pain of cervicogenic headache.
Destruction of a paravertebral facet joint nerve requires percutaneous placement of a needle or electrode at the level of the involved paravertebral facet joint’s medial branch nerve(s) under fluoroscopic or computed tomography (CT) guidance, and the injection of a local anesthetic agent to assure that the pain has been relieved (confirming that the needle is in the area desired to be denervated). Destruction of the paravertebral facet joint nerve can then be achieved by means of chemical, thermal, electrical or radiofrequency. Hypertonic saline, iced saline, or other methods of cryotherapy or standard electrocautery are considered ineffective and therefore, not “reasonable and necessary.” Pulsed radio-frequency using a radio frequency current at markedly lower temperature is considered investigational and not “reasonable and necessary.”
The standard of care for all paravertebral facet joint/nerve injections requires that these procedures be performed under fluoroscopic- or CT-guided imaging. Therefore, injections performed without imaging guidance will be denied as inappropriate and not reasonable or necessary.
The effects of denervation should last from six (6) months to one (1) year, or longer. In some instances, though, the effects may be permanent. Repeat denervation procedures at the same joint/nerve level will only be covered when the patient had significant improvement of pain after the initial facet joint nerve destruction that lasted an appropriate period of time (greater than or equal to six months).
Note:
General anesthesia or Monitored Anesthesia Care (MAC) is rarely, if ever required for paravertebral facet joint/nerve denervations. In fact, general anesthesia is contraindicated for diagnostic blocks (Manchikanti et al 2005). Monitored anesthesia care or heavy sedation may provide false-positive results.
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| Coding Information |
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Bill Type Codes: back to top
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. |
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Revenue Codes: back to top
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. |
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| CPT/HCPCS Codes back to top |
| 64622 |
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL |
| 64623 |
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 64626 |
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL |
| 64627 |
DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 77003 |
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL, TRANSFORAMINAL EPIDURAL, SUBARACHNOID, PARAVERTEBRAL FACET JOINT, PARAVERTEBRAL FACET JOINT NERVE, OR SACROILIAC JOINT), INCLUDING NEUROLYTIC AGENT DESTRUCTION |
| 77012 |
COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION |
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| ICD-9 Codes that Support Medical Necessity back to top |
| 719.48 |
PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES |
| 721.0 |
CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY |
| 721.1 |
CERVICAL SPONDYLOSIS WITH MYELOPATHY |
| 721.2 |
THORACIC SPONDYLOSIS WITHOUT MYELOPATHY |
| 721.3 |
LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY |
| 721.41 |
SPONDYLOSIS WITH MYELOPATHY THORACIC REGION |
| 721.42 |
SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION |
| 722.4 |
DEGENERATION OF CERVICAL INTERVERTEBRAL DISC |
| 722.51 |
DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC |
| 722.52 |
DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC |
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722.81 - 722.83
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POSTLAMINECTOMY SYNDROME OF CERVICAL REGION - POSTLAMINECTOMY SYNDROME OF LUMBAR REGION |
| 723.1 |
CERVICALGIA |
| 724.2 |
LUMBAGO |
| 724.8 |
OTHER SYMPTOMS REFERABLE TO BACK |
| 733.82 |
NONUNION OF FRACTURE |
| 738.4 |
ACQUIRED SPONDYLOLISTHESIS |
| 756.11 |
CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION |
| 756.12 |
SPONDYLOLISTHESIS CONGENITAL |
| 847.0 |
NECK SPRAIN |
| 847.1 |
THORACIC SPRAIN |
| 847.2 |
LUMBAR SPRAIN |
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| Diagnoses that Support Medical Necessity back to top |
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| ICD-9 Codes that DO NOT Support Medical Necessity back to top |
Any ICD9CM diagnosis code not listed in the "ICD9CM Codes that support Medical Necessity" section
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| ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation back to top |
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| Diagnoses that DO NOT Support Medical Necessity back to top |
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| General Information |
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| Documentation Requirements back to top |
The patient’s medical record should contain documentation that fully supports the medical necessity for paravertebral facet joint/nerve denervation as it is covered by Medicare (please see “Indications and Limitations of Coverage and/or Medical Necessity”). This documentation includes, but is not limited to, relevant medical history, physical examination, results of pertinent diagnostic tests or procedures.
Medical documentation in the patient’s medical record should substantiate the suspected diagnosis. As an example, "The patient had back pain without a strong radicular component, no associated neurologic deficit, and the pain was aggravated by hyperextension of the spine."
Medical documentation should also demonstrate that the patient’s pain has been refractory to repeated attempts at medical management prior to paravertebral facet joint/nerve injections. In addition, the medical records must document a positive response to the paravertebral joint/nerve block injection for the joint being denervated. A positive response is defined as significant pain relief of >/= 50% with the ability to perform previously painful maneuvers.
The following lists specific criteria that should be documented in the medical record: - Complete initial evaluation including history and physical examination;
- Physiological and functional assessment, as necessary and feasible;
- Description of indications and medical necessity, as follows:
- Suspected organic problem;
- Pain and disability of moderate-to-severe degree;
- No evidence of contraindications such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain;
- Nonresponsiveness to conservative modalities of treatment;
- Repeating interventions only upon return of pain and deterioration in functional status; and/or
- Responsiveness to prior interventions with improvement in physical and functional status for repeat blocks or other interventions.
The standard of care for all facet joint/nerve injections requires that these procedures be performed under fluoroscopic- or CT-guided imaging. An image (plain radiograph with conventional film or specialized paper, or digital) documenting the needle position must be obtained. A hard, or digital, copy of the needle placement should be retained to document accurate placement. Intraarticular radiofrequency is not appropriate.
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| Appendices back to top |
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| Utilization Guidelines back to top |
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.
In addition to the information in “Indications and Limitations of Coverage and/or Medical Necessity,” the following additional guidelines are presented. - Performing more than four (4) to six (6) denervations (e.g., two joints bilaterally) on the same date of service would usually not be anticipated and may be subject to review.
- Claims billed for denervation procedures performed more frequently than once every six months at the same target level will require supportive documentation describing the unusual clinical circumstances and response to prior therapy(ies). Please see “Indications and Limitations of Coverage and/or Medical Necessity.”
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| Sources of Information and Basis for Decision back to top |
Cohen S, Stojanovic, MP, Crooks, M, Kim, P, Schmidt, RK, Shields, CH, Croll, S, Hurley, RW. Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. The Spine Journal 2008;8:498-504.
LCD for Paravetebral Facet Joint Blocks (L26928). In: First Coast Service Options I, ed.; 2008.
Facet Joint Nerve Block (L22590). In: UMD HN, ed.; 2004.
Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007;106(3):591-614.
Ahadian FM. Pulsed radiofrequency neurotomy: advances in pain medicine. Curr Pain Headache Rep 2004 Feb; 8(1):34-40.
American Society of Anesthesiologists. Practice guidelines for chronic pain management. Anesthesiology 1997; 86:995-1004.
April C, Bogduk N. The prevalence of cervical zygapophyseal joint pain. Spine 1992; 17(7):744-747.
Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of cervical zygapophyseal joint pain. Regional Anesth 1993; 18:343-350.
Barnsley L, Lord SM, Wallis BJ, et.al. Lack of effect of intra-articular corticosteroids for chronic pain in the cervical zygapophyseal joints N. Engl. J. Med 1994; 330:1047-1050.
Barnsley L, Lord SM, et al. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20(1):20-26.
Barnsley L, Lord S, Bogduk N. Comparative local anesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain 1993; 55:99-106.
Barnsley L, Lord S, et al. False-positive rates of cervical zygapophysial joint blocks. Clinical J Pain 1993; 9:124-130.
Bogduk N, Clinical Anatomy of the Lumbar Spine and Sacrum, Churchill Livingstone 1997;127-247.
Bogduk N. International spinal injection society guidelines for the performance of spinal injection procedures. Part 1: Zygapophysial joint blocks. Clinical J Pain 1997; 13:285-302.
Boswell et al. Interventional Techniques in the Management of Chronic Spinal Pain: Evidence-Based Practice Guidelines. Pain Physician. 2005; 8:1-47.
Boswell MV, Colson JD, Spillane WF. Therapeutic facet joint interventions in chronic spinal pain: A systematic review of effectiveness and complications. Pain Physician 2005; 8:101-114 http://www.painphysicianjournal.com.
Catlin RW. Diagnostic and Therapeutic Injections. In: Tollison CD, Satterwaite JR, Tollison JW, editors. Practical pain management 3rd ed. Lippincott: Williams & Wilkins 2001; 83-106.
Carrier Medical Directors Chronic Pain Management Clinical Workgroup, model policies on paravertebral nerve blocks, paravertebral facet joint nerve blocks and paravertebral facet joint denervation, 1997.
Cohen SP, Raja, SN; Pathogenesis, Diagnosis, and Treatment of Lumbar Zygapophysial (Facet) Joint Pain, Anesthesiology. 2007;106: 591-614.
Dreyfus P, Schwarzer AC, et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine 1997; 22(8):895-902.
Lord SM, Barnsley L, et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal joint pain. N Engl J Med 1996; 335(23):1721-1727.
Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 2004; 5:15. http://www.biomedcentral.com.
Manchikanti L, Damron KS, Rivera J, McManus CD, Jackson SD, Barnhill RC, Martin JC. Evaluation of effect of sedation as a confounding factor in the diagnostic validity of lumbar facet joint pain: A prospective, randomized, double-blind, placebo-controlled evaluation. Pain Physician 2004; 7:407-410. http://www.painphysicianjournal.com.
Manchikanti L, Pampati V, Fellows B, Baha A. The inability of the clinical picture to characterize pain from facet joints, Pain Physician 2000; 3:(2):158-166. http://www.painphysicianjournal.com.
Manchikanti L, Pampati V, Damron KS, MCManus CD, Jackson SD, Barnhill RC, Martin JC. A randomized, prospective, double-blind, placebo-controlled evaluation of the effect of sedation on diagnostic validity of cervical facet joint pain. Pain Physician 2004; 7:301-310. http://www.painphysicianjournal.com.
Manchikanti L, Pampati V, Fellows B, Rivera JJ, Damron KS, Beyer CD. Influence of psychological factors on the ability to diagnose chronic low back pain of facet joint origin. Pain Physician 2001; 4:349-357. http://www.painphysicianjournal.com.
Manchikanti L, Singh V, Bakhit CE, Fellows B. Interventional techniques in the management of chronic pain. Part 1.0. Pain Physician 2000; 3:7-42. http://www.painphysicianjournal.com.
Manchikanti L, Statts PS, Singh V, Schultz DM, Vilims BD, Jasper JF et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2003; 6:3-81. http://www.asipp.org.
Mikeladze G, Espinal R, Finnegan R, Routon J, Martin D. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain. The Spine Journal 2003; 3: 360-362;
Revel M, Poiraudeau S, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine 1998; 23(18):1972-1976.
Schwarzer AC, Shih-Chang W, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: A study in an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54:100-106.
Schwarzer AC, Derby R, et al. Pain from the lumbar zygapophysial joints: A test of two models. J Spinal Disord 1994; 7(4):331-336.
Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: A systematic review of evidence. Pain Physician 2005; 8: 211-224.http://www.painphysicianjournal.com.
Tollison, CD, ed. Handbook of Pain Management, 2nd Edition. Baltimore: Williams & Wilkins, 1994.
Warfield CA, Principles and Practice of Pain Management, McGraw-Hill 2004.
Medicare Contractors’ Local Coverage Determinations
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| Advisory Committee Meeting Notes back to top |
| 02/11/2008 |
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| Start Date of Comment Period back to top |
| 02/11/2008 |
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| End Date of Comment Period back to top |
| 03/26/2008 |
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| Start Date of Notice Period back to top |
| 04/01/2008 |
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| Revision History Number back to top |
| R4 |
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| Revision History Explanation back to top |
R4
06/01/2009
In accordance with Section 911 of the Medicare Modernization Act of 2003, J14 MAC-Part B Contractor numbers ME-14102, MA-14202, NH-14302, VT-14502 (formerly Part B NHIC, Corp. ME-31142, MA-31143, NH-31144 and VT-31145) were added to this LCD.
R3
05/01/2009
In accordance with Section 911 of the Medicare Modernization Act of 2003, MAC-Part B -14402 Contractor number [formerly Part B Pinnacle (00524)] was added to this LCD.
R2
11/01/2008
1. Under Indications and Limitations of Coverage (Abstract), the following language was revised:
• “Facet joint arthropathy (joint disease) is diagnosed” was revised to “Facet joint arthropathy (joint disease) is generally diagnosed”
• “Facet joint denervation may be considered if double-comparative paravertebral facet joint/nerve blocks do provide significant pain relief, but the pain relief is not long-lasting.” was revised to “Facet joint denervation may be considered if double-comparative paravertebral facet joint/nerve blocks do provide significant pain relief, but the pain relief is not long-lasting (single diagnostic blocks are acceptable in anticoagulated patients requiring anticoagulation reversal)
2. Under Indications and Limitations of Coverage , the following language was revised:
“Significant pain relief is defined as greater than or equal to ≥80%-90% initially” was changed to “Significant pain relief is defined as greater than or equal to ≥50% initially”
3. Added ICD9CM diagnosis codes 719.48, 722.81-722.83, 723.1, 724.2, 724.8
4. Under Utilization Guidelines, the following language was revised:
“Performing more than two (2) to three (3) denervations per region (cervical, thoracic, lumbosacral) on the same date of service would usually not be anticipated and may be subject to review.” was changed to “Performing more than four (4) to six (6) denervations (e.g. two joints bilaterally) on the same date of service would usually not be anticipated and may be subject to review.”
5. Under Documentation Guidelines, the following language was revised:
“A positive response is defined as significant pain relief of >/= 80%-90% with the ability to perform previously painful maneuvers.” was changed to “A positive response is defined as significant pain relief of >/= 50% with the ability to perform previously painful maneuvers.”
6. Added the following references to Sources of Information:
- Cohen S, Stojanovic, MP, Crooks, M, Kim, P, Schmidt, RK, Shields, CH, Croll, S, Hurley, RW. Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. The Spine Journal 2008;8:498-504.
- LCD for Paravetebral Facet Joint Blocks (L26928). In: First Coast Service Options I, ed.; 2008.
- Facet Joint Nerve Block (L22590). In: UMD HN, ed.; 2004.
- Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007;106(3):591-614.
R1
03/26/2008
Official comment period ended. Draft released to final.
05/01/2009 In accordance with Section 911 of the Medicare Modernization Act of 2003, MAC-Part B -14402 Contractor number [formerly Part B Pinnacle (00524)] was added to this LCD.
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| Reason for Change back to top |
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| Last Reviewed On Date back to top |
| 06/01/2009 |
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| Related Documents back to top |
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