Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for radiofrequency ablation (CPT 64635 and 64636).In a systematic review, Manchikanti and colleagues reported on the effects of repeated radiofrequency ablation in patients having the procedure for the second and third time in the lumbar spine. The authors described a study by Rambarasingh and colleagues that assessed 104 patients. Per Manchikanti and colleagues, The results showed pain intensity, pain frequency, and patient-specific disability measures were significantly improved post-initial, second, and third radiofrequency neurotomy. Further, there was no statistically significant difference between the duration of the relief after the first radiofrequency neurotomy and pain relief after the second neurotomy. They concluded that repeated cervical and lumbar radiofrequency neurotomy reduces pain and disability with equal effectiveness for approximately 10 months in patients with chronic neck and back pain originating from facet joints. Moreover, McCormick and colleagues found radiofrequency ablation of the medial branch nerves for facet-mediated low back pain demonstrated clinical benefit for 6-12 months and possibly up to two years. A study by Lee and colleagues found that, Conventional radiofrequency denervation resulted in significant reductions in low back pain originating from the facet joints in patients showing the best response to diagnostic block over the first 12 months when compared with sham procedures or epidural nerve blocks.In this case, the patient has chronic low back pain with known facet joint arthropathy. The patient has successfully undergone lumbar medial branch blocks, most recently in December 2020, where he reported over 80% pain relief. Records from 8/20/19 state that the patient has successfully underwent previous lumbar radiofrequency ablation procedures three times over the last five years, with pain relief of 60-70% lasting for two and a half years. The patients low back pain has returned due to nerve regeneration, and a follow-up diagnostic injection confirmed the pain was still emanating from the facet joints. His treating provider is ordering a repeat procedure that was successfully done in the past. There is no need to repeat two diagnostic injections when the patient has already had beneficial relief over 50% from a previous lumbar radiofrequency ablation procedure. Additionally, the recent literature indicates that repeat ablation procedures are effective and provide durable back pain relief. Therefore, radiofrequency ablation (CPT 64635 and 64636) is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.