Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (L3-L4 bilateral) 
(CPT code 64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (L4-L5 bilateral and L5-S1 
bilateral) (CPT code 64636 X 2), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is a different procedure that uses a radio wave to heat a small area of 
nerve tissue. The Plan states the radio wave procedure has been proven to help with this type of pain. The Plan 
states the notes do not show that the enrollee will be having the radio wave procedure. The Plan states for this 
reason, this procedure is not medically necessary. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee had a prior lumbar radiofrequency ablative procedure bilaterally from L3 to the 
sacrum with an "excellent anesthetic phase relief that lasted over a year." There was no documentation on the 
percentage of improvement in pain or the percent improvement in the ability to perform previously painful 
movements and activities of daily living (ADLs) from procedure on July 17, 2021. However, there is no 
mention of which radiofrequency ablation (RFA) (date) the provider was referencing.  Per the coverage criteria, 
a repeat facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided 
the enrollee had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% 
consistent improvement in the ability to perform previously painful movements and ADLs as compared to 
baseline measurement using the same scale. Therefore, the review has determined that the medical records 
provided do not meet the requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (L3-L4 bilateral) (CPT code 64635) and destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or 
sacral, each additional facet joint (L4-L5 bilateral and L5-S1 bilateral) (CPT code 64636 X 2), for the enrollee.