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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation bilateral facet joints, L5-S1. Findings:  The physician reviewer found that American Society of Interventional Pain Physicians (ASIPP) guidelines for facet joint intervention states for the lumbar spine, The level of evidence is II with moderate strength of recommendation for lumbar radiofrequency ablation with inclusion of 11 relevant randomized controlled trials (RCTs) with two negative studies and four studies with long-term improvement. In a systematic review of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain, Machikanti and colleagues report that there is level II evidence on long-term effectiveness for radiofrequency neurotomy. Lee and colleagues report that 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 twelve months when compared with sham procedures or epidural nerve blocks. McCormick and colleagues report that radiofrequency ablation of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for six to twelve months and possibly up to two years. In this case, the patient has chronic low back pain believed to be facet joint related, and has undergone four previous lumbar radiofrequency ablation procedures of the L5-S1 with consistently at least six months of pain relief ranging from 50% to 60%. Notes reported that the patient had tried and failed other treatment modalities including L2-L5 fusion and left sacroiliac joint fusion prior to undergoing lumbar radiofrequency ablation. Given this patients response to treatment and duration of the benefit, the use of repeat radiofrequency ablation is supported by current pain management national guidelines and evidence based literature. Therefore, radiofrequency ablation bilateral facet joints, L5-S1, is likely to be more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested radiofrequency ablation bilateral facet joints, L5-S1, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts 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.