Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the RFA at two levels. We decided that the Plan does not have to 
pre-approve the RFA at a third level.  
 You asked the Plan to pre-approve radiofrequency ablation (RFA), three levels (C3-4, C4-5, C5-6).. You say 
that the enrollee continues to have pain despite conservative treatment. You also say that your pain is at a 6 out 
of 10. The Plan says that the request for RFA to be performed at three levels is not medically necessary. 
 
We decided that the Plan has to pre-approve the RFA at two levels.  
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (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 medically reasonable and necessary diagnostic 
medical branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). 
 
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 three levels. Our reviewer says 
that the requested radiofrequency ablation at two levels is medically necessary. Our physician reviewer found 
the guidelines limit radiofrequency ablation (RFA) to only two levels at one session. The reviewer found that 
the provided documentation supports the request for radiofrequency ablation (RFA) at two levels. Therefore, 
the reviewer found that RFA at two levels is 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 RFA at three levels have been met. Therefore, we decided that the Plan has to 
pre-approve the RFA at two levels.  
 
We also decided that the Plan does not have to pre-approve the RFA at a third level. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency ablation is limited to one to 
two levels, either unilateral or bilateral, per session per spine region. 
 
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 a third level. Our reviewer says 
that the requested radiofrequency ablation at two levels is medically necessary. Our physician reviewer found 
that RFA at a third level in a single session exceeds the limit set forth in the guidelines. Therefore, the reviewer 
found the request for an RFA at a third level 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 a third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the RFA at a third level. 
 
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.