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December 19, 2023

Pathway to an RFA Request for Facet Joints

Per our LCD L38773 Facet Joint Interventions for Pain Management, at least two confirmatory medial branch blocks (MBBs) in a row at the same level and/or site are required before pursuing a radio frequency ablation (RFA) procedure.

Initial thermal RFA:

After the patient has 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 (with the duration of relief being consistent with the agent used)

The first and second MBBs that are performed need to result in at least an 80% improvement in pain. To best demonstrate the 80%, there needs to be the same pain assessment scale conducted before and after each procedure. The scale can be used to determine if the 80% improvement has been achieved. Per our LCD:

*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the samepain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).

In addition to using the same pain scale, there also needs to be a functional disability scale completed prior to the first MBB. The functional assessment assists in determining how their pain specifically affects their abilities to do specific tasks. Many functional assessment scales provide measurable specific examples of how a patient's pain affects their ability to: do household chores, ride in a care for a length of time, stand and/or walk for a specific time or length, etc. Some functional scales combine both pain and function. There are many scales that can be used.

A physician can choose to use the functional scale before and after a procedure. Or, they can use the functional scale at baseline but then use an NRS/VAS before and after a procedure. Whatever scale is used for the procedures it needs to be the same and demonstrate that 80% improvement has been achieved.

When requesting an initial RFA, the following is needed:

  • All information, including the baseline functional assessment, related to the first MBB procedure
  • All information related to the second MBB procedure
  • Documentation the same pain scale was used for both procedures before and after which supports 80% improvement
  • Clear plan for the RFA procedure at the same levels/site the MBBs were performed
  • CGS will no longer be non-affirming if sedation is used. The use of sedation services may or may not be covered per CGS's LCD Facet Joint Interventions for Pain Management. Providers are responsible for making sure they have the documentation to support the use of sedation. Some specific examples include but are not limited to:
    • Medical condition that would interfere with the procedure
    • Specific well-described history of the patient's inability to cooperate
    • Well-described documentation related to the patient's inability to remain motionless or in a painful position for a prolonged period of time

When requesting a subsequent RFA, the following is needed:

  • Depending on when the last RFA was done, information related to the MBBs that were performed
  • Good documented history of previous RFA procedures
  • Documentation the RFA procedure resulted in at least 50% improvement in pain and/or functioning for at least 6 months
  • Documentation on when the last RFA was performed
  • Indications that the same symptoms are returning, and the pain is at the same level or levels

When requesting an RFA procedure, providers need to keep track of the number of sessions that have been provided. A session can be unilateral or bilateral. There can only be 2 RFA sessions within a 12-rolling month period for the same region of the spine. If the number of sessions exceeds what is allowable for a region, any claims submitted may be denied or non-covered.

Session examples:

A patient receives unilateral RFA sessions.

  • RT RFA procedure L3-4, L4-5 on November 1, 2023 = session 1
  • LT RFA procedure L3-4, L4-5 on November 20, 2023 = session 2
  • Patient's pain returns September 15, 2024 in the same region
    • Documentation shows sustained 50% improvement for at least 6 months
    • Cannot receive another RFA until after November 1, 2024 at the earliest

A patient receives bilateral RFA sessions.

  • BL RFA procedure L3-4, L4-5 on November 1, 2023 = session 1
  • Patient's pain returns in the same area on May 15, 2024
    • Documentation shows patient sustained at least 50% improvement for at least 6 months
    • BL RFA procedure L3-4, L4-5 performed on May 30, 2024 = session 2
  • Patient cannot receive another RFA until on/after November 30, 2024 at the earliest
    • Patient needs to have 50% improvement for at least 6 months between sessions

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