Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for right and left C3-5 radiofrequency ablation
with sedation.
You asked the Plan to pre-approve coverage for right and left C3-5 radiofrequency ablation with sedation. You
say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria are not met. Maximus partially overturned the Plans decision. After that decision was made, an error
was found, and the case was reopened.
Our Medical Director review the case file. At issue is coverage for right and left C3-5 radiofrequency ablation
with sedation. The enrollee is a 43-year-old woman with neck pain. Her diagnoses include chronic pain
syndrome, cervico-occipital neuralgia, arthropathy of cervical spine facet joint, and cervical spondylosis.
On August 8, 2023, the enrollee stated that after a procedure she had good relief lasting 6-8 hours before her
symptoms returned. The pain was 70% localized, and 30% radiating. The medical records show on July 25,
2023, 7/25/2023 - Bilateral C3-5 MBB provided 80% relief for 2 days. On January 26, 2023, Bilateral C4-6
RFA provided 80% relief for 2 weeks. On July 18, 2022, Bilateral C3-6 RFA provided 75% relief x ongoing.
On June 13, 2022, Bilateral C3-6 MBB provided 80% relief for 6-8 hours. On November 18, 2021, Bilateral
C3-6 MB RFA provided 70% relief for 6 months. On November 15, 2021, Bilateral C3-6 RFA provided 20%
relief. On October 15, 2021, Bilateral C3-6 MBB provided 80% relief for 6 hours. In addition, since September
3, 2021, the enrollee has received 7 bilateral occipital nerve blocks, 6 Botox injections, and 2 trigger point
injections.
In Consensus Practice Guidelines, the committee recommends that if an initial RFA is successful (clinically
meaningful pain relief for =3 months), it should be offered to patients who experience return of their cervical
pain, assuming that the pain is similar in character and location to the initial pain, grade B, moderate level of
certainty. Given the mean duration of benefit and drop-off in success rates noted in some studies with repeat
RFA, we recommend repeating the procedure no more than two times a year; grade B, moderate level of
certainty. Although there are a paucity of studies examining cervical medial branch RFA success rates after
repeating prognostic blocks, the high success rates reported after empirically repeating RFA indicate they are
not necessary in most people; grade C, low level of certainty.
LCD L34892 states: Therapeutic facet joint procedures are considered medically reasonable and necessary for
patients who meet ALL of the following criteria:
1. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each
one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being
consistent with the agent used); AND
2. Subsequent therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% pain
relief for at least three (3) months from the prior therapeutic procedure 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; AND
3. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal
pseudarthrosis, implanted electrical device) is in the medical record.
The clinical documentation does not support that subsequent therapeutic facet joint procedures at the same
anatomic site resulted in at least consistent 50% pain relief for at least three (3) months from the prior
therapeutic procedure. Procedures in 2023 (Bilateral C4-6 RFA and Bilateral C3-5 MBB) have not provided
clinically meaningful pain relief lasting longer than 3 months. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of coverage for right and left C3-5 radiofrequency ablation with sedation have not
been met. Therefore, we decided that the Plan does not have to pre-approve coverage for right and left C3-5
radiofrequency ablation with sedation.