Are services 64633 and 64634 (Destruction by neurolytic agent of paravertebral facet joint nerve(s)) medically necessary for a patient with a diagnosis of Spondylosis without Myelopathy or Radiculopathy, Cervical Region (M47.812)?

Medical Necessity Determination for Cervical Facet Radiofrequency Ablation

CPT codes 64633 and 64634 are NOT medically necessary for this patient with cervical spondylosis without myelopathy or radiculopathy (M47.812), as the diagnosis does not meet established criteria for facet joint denervation procedures.

Critical Diagnostic Mismatch

The fundamental issue is that the patient's diagnosis explicitly excludes both myelopathy AND radiculopathy 1. This creates a significant problem for medical necessity determination:

• The diagnosis M47.812 specifically indicates spondylosis WITHOUT myelopathy or radiculopathy 1
• Facet joint radiofrequency ablation requires documented facet-mediated pain as the primary pain generator 1
• Without radicular symptoms or myelopathic findings, the clinical presentation must demonstrate clear facet joint pathology through diagnostic criteria 1

Required Medical Necessity Criteria Not Met

Based on American College of Radiology guidelines, the following mandatory prerequisites must be satisfied before facet denervation can be considered medically necessary 1:

Prerequisite 1: Duration and Severity Requirements

• Severe pain limiting activities of daily living for at least 6 months is required 1
• Documentation must demonstrate functional impairment, not just pain complaints 1

Prerequisite 2: Conservative Treatment Failure

• Six or more weeks of failed conservative treatments including bed rest, back supports, physiotherapy, postural correction, and pharmacotherapies 1
• Each modality attempted must be documented with dates and patient response 1

Prerequisite 3: Diagnostic Confirmation

• Two positive diagnostic facet joint injections at the level to be treated showing at least 80% relief of facet-mediated pain 1
• This is the most critical requirement - without documented positive diagnostic blocks demonstrating facet-mediated pain, the procedure cannot be justified 1

Prerequisite 4: Exclusion of Alternative Pathology

• Neuroradiologic studies must be negative or fail to confirm disc herniation 1
• Imaging must support facet joint pathology as the primary pain generator 1

Clinical Context and Common Pitfalls

Poor Correlation Between Imaging and Symptoms

• Spondylotic changes on radiographs and MRI are common in patients over 30 years of age and correlate poorly with the presence of neck pain 1
• Imaging findings in cervical spondylosis correlate poorly with symptoms, as degenerative changes are commonly found in asymptomatic individuals 1
• The presence of spondylosis on imaging alone does not justify interventional procedures 1

Natural History Considerations

• Cervical spondylosis is a common degenerative condition that often presents with neck pain, but many cases resolve spontaneously or with conservative treatment 1
• Evidence of spondylitic change is frequently found in many asymptomatic adults 2
• The diagnosis of spondylosis without myelopathy or radiculopathy represents a less severe presentation that typically responds to conservative management 1

Appropriate Management Algorithm

Step 1: Conservative Management (Minimum 6 Weeks)

• NSAIDs and acetaminophen for pain control 1
• Physical therapy with focus on postural correction 1
• Activity modification and ergonomic adjustments 1
• Back supports as needed 1

Step 2: Extended Conservative Trial (Up to 6 Months)

• Continue conservative measures if showing any improvement 1
• Consider MRI cervical spine without contrast only if symptoms persist or worsen beyond 6 weeks 1
• Radiographs may be useful to diagnose spondylosis but rarely alter therapy in the absence of red flag symptoms 1

Step 3: Diagnostic Facet Injections (Only After 6 Months of Severe Pain)

• Diagnostic facet joint injections may be considered to confirm facet-mediated pain after 6 weeks of conservative management 1
• Two separate diagnostic blocks are required, each showing at least 80% pain relief 1
• Only proceed to ablation if both diagnostic blocks are positive 1

Step 4: Radiofrequency Ablation (Only If All Criteria Met)

• Can only be considered after all above steps are completed and documented 1
• Must have two positive diagnostic blocks 1
• Must have failed 6+ weeks of comprehensive conservative care 1
• Must have severe pain limiting ADLs for at least 6 months 1

Key Documentation Gaps to Address

Without access to the complete medical record, the following critical information would need to be present to support medical necessity:

• Duration of symptoms (must be ≥6 months of severe pain) 1
• Specific conservative treatments attempted with dates and outcomes 1
• Results of two separate diagnostic facet joint injections showing ≥80% relief 1
• Functional impairment documentation demonstrating limitation in activities of daily living 1
• Imaging studies excluding disc herniation or other pathology 1

Distinction from Myelopathy and Radiculopathy

The provided guidelines primarily address cervical spondylotic myelopathy (CSM) and radiculopathy, which are explicitly excluded by this patient's diagnosis 3:

• Guidelines for CSM recommend both operative and nonoperative options for younger patients with mild disease 3
• In patients with cervical stenosis without myelopathy, decompression should be considered if abnormal EMG findings or clinical radiculopathy are present 3
• This patient has neither myelopathy nor radiculopathy, placing them in a different clinical category 1

Final Determination

The services are NOT medically necessary based on the diagnosis provided (M47.812) without documentation of:

1. Six months of severe pain limiting ADLs 1
2. Six or more weeks of failed conservative treatment 1
3. Two positive diagnostic facet joint injections with ≥80% relief 1
4. Imaging excluding alternative pathology 1

The diagnosis of cervical spondylosis without myelopathy or radiculopathy represents a condition that typically responds to conservative management and does not automatically warrant interventional procedures 1, 2.