Description
Facet joints, (also called zygapophyseal joints or z-joints), posterior to the vertebral bodies in the spinal column and connecting the vertebral bodies to each other, are located at the junction of the inferior articular process of a more cephalad vertebra and the superior articular process of a more caudal vertebra. These joints provide stability and enable movement, allowing the spine to bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.^1,12

Facet joints are clinically important spinal pain generators in individuals with chronic spinal pain. In 15% – 45% individuals with chronic low back pain, facet joints have been implicated as a cause of the pain. Facet joints are considered as the cause of chronic spinal pain in 48% of individuals with thoracic pain and 54% – 67% of individuals with chronic neck pain.¹³ Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck, and shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome,’ a term originally used by Ghormley¹⁴ in 1933, referring to back pain caused by pathology at the facet joints. Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting individuals for controlled local anesthetic blocks of either the medial branches or the facet joint itself.¹⁵

Facet joints are known to be a source of pain with definitive innervations. Interventions used in the treatment of individuals with a confirmed diagnosis of facet joint pain include medial branch nerve blocks in the lumbar, cervical, and thoracic spine; and radiofrequency neurolysis (see additional terminology). The medial branch of the primary dorsal rami of the spinal nerves has been shown to be the primary innervations of facet joints. Substance P, a physiologically potent neuropeptide considered to play a role in the nociceptive transmission of nerve impulses, is found in the nerves within the facet joint.^1,16,17

Radiofrequency neurolysis is a minimally invasive treatment for cervical, thoracic, and lumbar facet joint pain. It involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. The objective of radiofrequency neurolysis is to both provide relief of pain and reduce the likelihood of recurrence.¹⁸

Members of the American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) have agreed that conventional or thermal radiofrequency ablation of the medial branch nerves to the facet joint should be performed for neck or low back pain.19 Radiofrequency neurolysis has been employed for over 30 years to treat facet joint pain. Prior to performing this procedure, shared decision-making between patient and physician must occur, and the patient must understand the procedure and its potential risks and results.

Overview:
THERAPEUTIC PARAVERTEBRAL FACET JOINT DENERVATION (RADIOFREQUENCY NEUROLYSIS): Local anesthetic block is followed by the passage of radiofrequency current to generate heat and coagulate the target medial branch nerve. Traditional radiofrequency and cooled radiofrequency are included by this definition. Pulsed radiofrequency, cryo-ablation, or laser ablation are not included in this definition.

*Conservative Therapy — Non-operative treatment should include a multimodality approach consisting of a combination of active and inactive components. Inactive components can include rest, ice, heat, modified activities, medical devices, acupuncture, stimulators, medications, injections, and diathermy. Active modalities should be region-specific (targeting the cervical, thoracic, or lumbar spine) and consist of physical therapy, a physician-supervised home exercise program**, or chiropractic care.^3,4,20

**Home Exercise Program (HEP) — The following two elements are required to meet guidelines for completion of conservative therapy:

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor^4,5,21; AND
• Follow-up documentation regarding completion of HEP after the required 6-week time frame or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises). Closure of medical offices, closure of therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” HEP.^3,4

Terminology: Paravertebral Facet Joint Denervation, Radiofrequency Neurolysis, Destruction Paravertebral Facet Joint Nerve, Facet Joint Rhizotomy, Facet Neurolysis, Medial Branch Radiofrequency Neurolysis, Medial Branch Radiofrequency Neurotomy or Radiofrequency Denervation.

Policy:  

GENERAL INFORMATION
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

INDICATIONS  FOR  PARAVERTEBRAL FACET JOINT DENERVATION/RADIOFREQUENCY NEUROLYSIS: 

For the treatment of facet-mediated pain ALL of the following must be met:

• Lack of evidence that the primary source of pain being treated is from sacroiliac joint pain, discogenic pain, disc herniation or radiculitis^1,2
• Pain causing functional disability or average pain levels of > 6 on a scale of 0 to 10 ^1,2,3
• Duration of pain of at least 3 months^1,3
  • Positive response to at least one or two controlled local anesthetic blocks of the facet joint nerves (medial branch blocks), with at least 70% pain relief or improved ability to function for a minimal duration at least equal to that of the local anesthetic, but with insufficient sustained relief (less than 2 – 3 months relief)^1,2,3
  • Failure to respond to non-operative conservative therapy* targeting the requested spinal region for a minimum of 6 weeks in the last 6 months unless the medical reason this treatment cannot be done is clearly documented^1,2,3

NOTE: All procedures must be performed using fluoroscopic or CT guidance.^6,7

INDICATIONS FOR REPEAT PROCEDURES
Facet joint denervation procedures may be repeated only as medically necessary. Each denervation procedure requires an authorization, and the following criteria must be met for repeat procedures:

• Positive response to prior radiofrequency denervation procedures with at least 50% pain relief or improved ability to function for at least 4 months^1,3,4,5
• The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 – 10^1,2,3
• The individual is engaged in ongoing non-operative conservative therapy *unless the medical reason this treatment cannot be done is clearly documented.^1,3,4,5

REPEAT PROCEDURES
Facet joint denervation procedures may be repeated only as medically necessary. Each denervation procedure requires an authorization, and the following criteria must be met

• A maximum of 2 facet denervation procedures maybe be performed in a 12-month period per spinal region1
  • Unilateral radiofrequency denervation’s performed at the same level(s) on the right vs left within 1 month of each other would be considered as one procedure toward the total number of radiofrequency procedures allowed per 12 months. There is no minimum timeframe required between these procedures on the right vs left. Opposite side denervation procedures performed at the same level(s) within 1 month of the first side do not require follow-up information to be submitted.

NOTE: It is generally considered not medically necessary to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient).

EXCLUSIONS
These requests are excluded from consideration under this guideline:

• Radiofrequency denervation of the sacroiliac joint and/or sacral lateral branches (S1, S2, S3)

CONTRAINDICATIONS FOR FACET JOINT DENERVATION

• Active systemic or spinal infection
• Skin infection at the site of needle puncture

References:  

1. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013;16(2 Suppl):S49-283.
2. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. Jul-Aug 2009;12(4):699-802.
3. Summers J. International Spine Intervention Society Recommendations for treatment of Cervical and Lumbar Spine Pain. 2013.
4. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Apr 4 2017;166(7):514-530. doi:10.7326/m16-2367
5. Sculco AD, Paup DC, Fernhall B, Sculco MJ. Effects of aerobic exercise on low back pain patients in treatment. Spine J. Mar-Apr 2001;1(2):95-101. doi:10.1016/s1529-9430(01)00026-2
6. Weininger M, Mills JC, Rumboldt Z, Bonaldi G, Huda W, Cianfoni A. Accuracy of CT guidance of lumbar facet joint block. AJR Am J Roentgenol. Mar 2013;200(3):673-6. doi:10.2214/ajr.12.8829
7. Amrhein TJ, Joshi AB, Kranz PG. Technique for CT Fluoroscopy-Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation. AJR Am J Roentgenol. Sep 2016;207(3):631-4. doi:10.2214/ajr.15.15694
8. Health technology reviews: facet neurotomy. Washington State Health Care Authority. Updated 2022. Accessed September 22, 2022. http://hca.wa.gov/about-hca/programs-and- initiatives/health-technology-assessment/facet-neurotomy
9. Facet neurotomy. Washington State Health Care Authority. Updated May 16, 2014. Accessed September 22, 2022. http://hca.wa.gov/assets/program/052714_facet_final_findings_decision[1].pdf
10. Facet neurotomy: assessing signals for update. Washington State Health Care Authority. Updated May 28, 2020. Accessed September 22, 2022. http://hca.wa.gov/assets/program/facet-neurotomy-assessing-signals-update-20200528.pdf
11. About the Health Care Authority (HCA). Washington State Health Care Authority. Updated 2022. Accessed September 22, 2022. http://hca.wa.gov/about-hca
12. Kim BY, Concannon TA, Barboza LC, Khan TW. The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review. Diagnostics (Basel). Dec 9 2021;11(12)doi:10.3390/diagnostics11122311
13. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5:15-15. doi:10.1186/1471-2474-5-15
14. Ghormley RK. Low back pain: with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101(23):1773-1777.
15. Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol. 2013;9(4):216-224. doi:10.1038/nrrheum.2012.199
16. Kallakuri S, Li Y, Chen C, Cavanaugh JM. Innervation of cervical ventral facet joint capsule: Histological evidence. World J Orthop. Feb 18 2012;3(2):10-4. doi:10.5312/wjo.v3.i2.10
17. Li W, Gong Y, Liu J, et al. Peripheral and Central Pathological Mechanisms of Chronic Low Back Pain: A Narrative Review. J Pain Res. 2021;14:1483-1494. doi:10.2147/jpr.S306280
18. Lee DW, Pritzlaff S, Jung MJ, et al. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2021;14:2807-2831. doi:10.2147/jpr.S325665
19. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2010;112(4):810-33. doi:10.1097/ALN.0b013e3181c43103
20. American College of Radiology. ACR Appropriateness Criteria® Low Back Pain. American College of Radiology (ACR). Updated 2021. Accessed August 2, 2022. https://acsearch.acr.org/docs/69483/Narrative/
21. Durmus D, Unal M, Kuru O. How effective is a modified exercise program on its own or with back school in chronic low back pain? A randomized-controlled clinical trial. J Back Musculoskelet Rehabil. 2014;27(4):553-61. doi:10.3233/bmr-140481

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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