Medical Necessity Determination for Thoracic Facet Joint Radiofrequency Ablation
Based on the clinical documentation provided, the requested cervical/thoracic radiofrequency ablation (CPT 64633, 64634x2) is medically necessary and meets established criteria, though the anesthesia code 01939 requires clarification as it is not standard for this outpatient procedure. 1
Clinical Justification
Patient Meets Core Criteria
The patient demonstrates all essential requirements for thoracic facet joint radiofrequency denervation:
Chronic pain duration >3 months: Patient has documented chronic thoracic pain with significant functional impairment affecting work and daily activities 2
Failed conservative management: Over 12 weeks of physician-directed conservative care including NSAIDs, pain creams, lidocaine patches, heat therapy, and stretching exercises 1
Positive diagnostic blocks: Two separate bilateral thoracic medial branch blocks (MBBs) at T9-12 with >80% pain relief on both occasions (first trial 85-90%, second trial >80%), meeting the dual positive block requirement 1
Functional improvement documented: Patient reported decreased pain, increased range of motion, ability to teach all day with less pain, improved cooking/cleaning activities, and overall improved quality of life following diagnostic blocks 2
Anatomical and Imaging Considerations
The presence of a right paracentral disc herniation at T6-7 does NOT contraindicate the procedure at T9-12 levels, as these are separate anatomical regions and the patient's pain pattern responded specifically to T9-12 medial branch blocks 1. The ACR Appropriateness Criteria note that thoracic disc abnormalities are common in asymptomatic patients and morphologic imaging changes do not correlate with facet-mediated pain 1.
The MRI findings of multilevel disc desiccation and spondylosis with mild chronic compression deformity at T11 support facet joint involvement as a pain generator 3. Radiofrequency ablation is specifically indicated for chronic pain originating from spondylosis when diagnostic blocks confirm facet joint origin 3.
Evidence Supporting Thoracic Facet RFA
Efficacy Data
Thoracic facet denervation demonstrates substantial long-term benefit: A study of 40 patients with chronic thoracic spinal pain showed 47.5% were pain-free at 2 months, with 35% having >50% pain relief 2. At long-term follow-up (average 31 months), 44% remained pain-free and 39% maintained >50% pain relief 2.
The American Society of Anesthesiologists guidelines state that conventional or thermal radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections have provided temporary relief 1. While this guideline specifically addresses lumbar spine, the British Pain Society emphasizes that outcomes of radiofrequency denervation have improved with better patient selection and technique, and medial branch blocks are recommended to diagnose facet joint pain followed by radiofrequency denervation in the context of multidisciplinary care 1.
Technical Considerations
The procedure should be performed under fluoroscopic guidance as emphasized by multiple guidelines 1. The patient is requesting unilateral (left-sided) treatment at three levels (T9-10, T10-11, T11-12), which is within the recommended maximum of treating no more than a certain number of levels during the same session 1.
Addressing the Anesthesia Code (01939)
CPT code 01939 (anesthesia for percutaneous image-guided destruction by neurolytic agent, cervical/thoracic) is NOT typically separately billable for outpatient radiofrequency ablation procedures. This is an anesthesia code that would only be appropriate if monitored anesthesia care or general anesthesia is being provided by a separate anesthesia provider 1. Standard thoracic facet RFA is performed with local anesthesia and does not require separate anesthesia services. The insurance policy documentation does not list 01939 as a covered code for this indication.
Diagnosis Code Considerations
The primary diagnosis M47.814 (spondylosis without myelopathy or radiculopathy, thoracic region) is appropriate and supported by imaging findings and clinical presentation 3.
G89.4 (chronic pain syndrome) is appropriate given the documented chronic nature and functional impact 2.
G47.33 (obstructive sleep apnea) is NOT relevant to the medical necessity determination for this procedure and should not be used as a supporting diagnosis for facet joint ablation. This is an incidental comorbidity that may affect perioperative management but does not influence the indication for the procedure.
Potential Concerns and Contraindications
Prior Spinal Surgery
The patient has a history of previous right thoracic RFA at T1-4 with 70-80% improvement. This prior successful intervention actually supports the current request, as it demonstrates the patient responds well to radiofrequency ablation 4. However, the literature suggests that patients with extensive prior spine surgery may have reduced benefit 4. The current request is for different levels (T9-12 vs previous T1-4), which is appropriate.
Radicular Involvement
The absence of radiculopathy is favorable for success. Studies show that long-term pain relief is significantly impaired by the presence of radicular compression, with 97% of such patients not achieving adequate pain relief from facet denervation 4. This patient's diagnosis specifically states "without myelopathy or radiculopathy," which is optimal 1.
Disc Herniation at T6-7
While there is a right paracentral disc herniation at T6-7 with thecal sac indentation, this does not affect the T9-12 levels being treated and the patient's positive response to diagnostic blocks at T9-12 confirms facet-mediated pain at those specific levels 1. The ACR guidelines emphasize that thoracic disc abnormalities are common in asymptomatic patients and do not correlate with facet joint pain 1.
Recommendation Summary
APPROVE CPT codes 64633 and 64634x2 for left-sided thoracic facet joint radiofrequency ablation at T9-10, T10-11, and T11-12 based on:
- Documented chronic pain >3 months with functional impairment 2
- Failed conservative treatment >12 weeks 1
- Two positive diagnostic medial branch blocks with >80% relief 1
- Appropriate imaging without contraindications 1, 3
- Evidence supporting efficacy in thoracic facet pain 2
DO NOT APPROVE CPT code 01939 as separate anesthesia services are not medically necessary for this outpatient procedure performed under local anesthesia 1.
The procedure should be performed under fluoroscopic guidance with appropriate documentation of technique and outcomes 1. Post-procedure rehabilitation and physical therapy should be coordinated to maximize functional improvement during the pain relief period 1.