Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the sedation services. We decided that the Plan does not have to 
pre-approve the RFA at C3-C5.  
 
You asked the Plan to pre-approve RFA and moderate sedation services (99152, 99153). You say that  the 
enrollee's severe neck pain is 70% localized. You say that a right side C3 to C5 RFA with sedation and a left 
side C3 to C5 RFA with sedation have been scheduled for August 25, 2023, and August 28, 2023, respectively. 
You also say that the sedation is medically necessary due to the enrollee's anxiety with needles and the inability 
to hold still for the procedure. The Plan says that the records do not show that the enrollee had significant relief 
from the prior RFA procedure. The Plan says the most recent MBB was only performed one time. The Plan 
also says that the records do not show that the sedation is medically necessary. 
 
We decided that the Plan has to pre-approve the sedation services.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
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 sedation. Our reviewer says that the 
requested sedation services are medically necessary. Our physician reviewer found sedation is noted in clinical 
practice guidelines. Therefore, the reviewer found that the requested sedation services are medically reasonable 
and necessary.   
 
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 sedation services have been met. Therefore, we decided that the Plan has to 
pre-approve the sedation services.  
 
We also decided that the Plan does not have to pre-approve the RFA at C3-C5. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
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 RFA at C3-C5. Our reviewer says that 
the requested RFA at C3-C5 is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee had bilateral medial branch blocks performed on July 25, 2023, with 80% 
pain reduction. The documentation does not provide evidence that a second MBB was performed. Therefore, 
the reviewer found that the requested RFA at C3-C5 is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA at C3-C5 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the RFA at C3-C5. 
 
 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.