Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis (64635).
You asked the Plan to pre-approve lumbar/sacral facet joint radiofrequency neurolysis (64635). You say that the requested lumbar/sacral facet joint radiofrequency neurolysis is medically necessary. The Plan denied your request. The Plan says the requested lumbar/sacral facet joint radiofrequency neurolysis does not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar/sacral facet joint radiofrequency neurolysis (64635). Our reviewer says that the requested lumbar/sacral facet joint radiofrequency neurolysis does not meet criteria. Our physician reviewer found the member is being treated for chronic pain. An MRI scan of the lumbar spine on 12/20/2019 showed findings of degenerative changes at the L4/5 level. There was multilevel disc bulging. Findings were similar to a prior scan in May 2017. Comorbid conditions include obesity, fibromyalgia, hyperlipidemia, hypertension, and vitamin deficiencies. She was seen for follow-up on 01/09/2020. She was being seen for a reevaluation and review of her lumbar MRI. She reported no substantial change and was having constant low back pain without clear radicular symptoms. She had an average daily pain score rated at 6/10 which was worse with activity. She was no longer able to complete her daily activities without increased pain. Medications included gabapentin, hydrocodone, and tizanidine with some relief. Her treatments had included physical therapy, osteopathic, and chiropractic care. She had undergone 3 prior medial branch radiofrequency ablations with relief reported. She had recently undergone an epidural injection without relief. There was no history of spinal surgery. Physical examination findings included a body mass index of 36. She had mild tenderness at the lumbosacral junction. She had limited motion with pain on both flexion and extension. Straight leg raising was negative. There was no lower extremity atrophy or weakness. The MRI result was reviewed. The treatment plan included a right L3-5 medial branch radiofrequency ablation. She was to follow-up one month afterwards.
There is no adequate description in terms of the degree and duration of pain relief after the 3 radiofrequency ablations performed. Additionally, there are no clinical findings that support the presence of right sided facet mediated pain such as right-sided facet tenderness or reproduction of symptoms with facet loading or range of motion. For these reasons she does not meet criteria for the requested radiofrequency neurolysis under the applicable LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar/sacral facet joint radiofrequency neurolysis (64635) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis (64635).