Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollees chronic pain. Findings:  Two physician reviewers found that the patient has chronic low back pain.  She is status post posterior lumbar fusion at L4-5 and intrathecal pump placement for chronic low back pain.  The patients medications include oxycodone, Baclofen, and intrathecal bupivacaine.  Sacroiliac joint injections were performed, which reportedly resulted in more than 50% reduction in her pain.  Four months later a physical examination was significant for tenderness to palpation over the bilateral sacroiliac joints, tenderness to palpation of the mid-lumbar spine, as well as the lower lumbar facets, positive Patricks test bilaterally, pain on external rotation of the bilateral hips, antalgic gait assisted with a cane, and 5/5 motor strength limited by pain.  The patient underwent bilateral radiofrequency ablation of medial branch at L5 and the lateral branches at the S1, S2, and S3 levels. Several months later she reported recurrent low back pain and lower extremity pain. The patient has requested coverage for radiofrequency neurolysis.  The Health Plan has denied this request and reported that the requested services are investigational for the treatment of this patient. Radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In this patients case, she did not have pre-ablation treatment with diagnostic medial branch/lateral branch blocks.  The current medical evidence does not support radiofrequency neurolysis in this clinical setting.  The standard of care in this patients case includes ongoing physical therapy, medications, or diagnostic medial branch blocks to determine if she is a candidate for another radiofrequency neurolysis.Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation.  They concluded that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting.  It is appropriate to perform diagnostic lumbar facet blocks and quantify patient response in order to determine whether the patient would remain a good candidate for rhizotomy.  Dreyfuss and colleagues performed a prospective study to establish the efficacy of lumbar medial branch neurotomy under optimal conditions.  The study established that lumbar medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks.  The study further asserted that controlled diagnostic blocks with documented reduction in pain following the blocks and prior to radiofrequency neurotomy ensured that patients had zygapophyseal joint pain.  In sum, the current medical evidence has not demonstrated the superior efficacy of the requested radiofrequency neurolysis in this patients case.