Documentation and Medical Necessity - Ablative Treatment for Spinal Pain - UHC Medical Policy

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Sep 21st, 2015 - Reviewed/Updated Aug 7th

According to UnitedHealthcares policy: For chronic cervical, thoracic and lumbar pain, Thermal radiofrequency ablation of facet joint nerves is proven and medically necessary when confirmed by the following:

•  Temperature 60 degrees Celsius or more;
•  Duration of ablation 40 - 90 seconds
•  Positive response to medial branch block injection at the side and level of the proposed ablation  and
•  Confirmation of needle placement by fluoroscopic guided imaging. 

UHC policy also states, Thermal radiofrequency ablation is proven and medically necessary:

• When performed at a frequency of six months or longer (maximum of 2 times over a 12 month period); and
• Provided there has been a 50% or greater documented reduction in pain for 10 to 12 weeks.

and is unproven and not medically necessary:

• When performed more frequently than every six months; or
• When there has been no significant improvement after medial branch block injection.

The policy states "Ablation procedures performed more frequently than every 6 months increase the risk of adverse events without improving the clinical outcome".

Required documentation for the above procedures must include:

• Temperature of administration of procedure
• Duration of ablation
• Specific identification of side and level of medial branch blocks
• Specific cervical, thoracic and/or lumbar ablated by side and level
• Percentage of pain relief with prior ablation if applicable
• Duration of improvement from previous ablation if applicable

Thermal radiofrequency ablation is considered unproven and not medically necessary for the treatment of all other causes of spinal pain including but not limited to the following:

• Diabetic neuropathy 
• Sacroiliac pain
• Complex regional pain syndrome or regional pain disorders and syndromes in the absence of spinal pain
• Definitive clinical and/or imaging findings identifying a condition requiring surgical treatment
• Identified specific causes of spinal pain (e.g., disc herniation) requiring definitive treatment

 Coding Clarification CPT codes 64633, 64634, 64635, and 64636 only apply to thermal radiofrequency ablation. CPT code 64999 is to be used for pulsed radiofrequency ablation.

Read the entire Policy here