Is medication or surgery medically indicated for a patient with lumbar spondylosis, who underwent procedures coded as 64635 and 64636, with a diagnosis code of M47.816?

Medical Necessity Assessment for Lumbar Medial Branch Radiofrequency Ablation

The procedures coded as 64635 and 64636 (lumbar medial branch radiofrequency ablation) are medically indicated for this patient with lumbar spondylosis (M47.816), as these represent appropriate conservative management for facet-mediated axial back pain prior to considering more invasive surgical interventions. 1, 2

Understanding the Procedure Codes

• CPT 64635: Destruction by neurolytic agent, paravertebral facet joint nerve (first level)
• CPT 64636: Each additional level (add-on code)
• These codes represent radiofrequency ablation of the medial branch nerves that innervate the lumbar facet joints 1

Clinical Rationale for Medical Necessity

Conservative management is the first-line approach for lumbar spondylosis, and radiofrequency ablation represents an intermediate step in the treatment algorithm before surgical consideration:

• The majority of patients with lumbar spondylosis can be treated nonsurgically, with operative therapy reserved only for patients who are totally incapacitated by their condition 2
• Conservative management strategies for lumbar spondylosis include non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy 3
• Radiofrequency ablation serves as a bridge therapy when simpler conservative measures fail but before proceeding to surgical decompression or fusion 1, 2

Position in Treatment Algorithm

Radiofrequency ablation is appropriately positioned after failure of initial conservative measures but before surgical intervention:

• Patients should first undergo trials of NSAIDs, COX-2 inhibitors, prostaglandins, and epidural or transforaminal injections 2
• If these measures provide inadequate relief, radiofrequency ablation of medial branch nerves can provide longer-lasting pain control than repeated injections 1
• Surgery should only be considered after comprehensive conservative management, including radiofrequency ablation, has been exhausted 2, 3

Evidence Supporting This Approach

Guidelines consistently emphasize exhausting conservative options before surgical consideration:

• A trial of conservative therapy should be considered for patients with degenerative spondylolisthesis presenting with radiculopathy and/or pseudoclaudication, including physical therapy, epidural steroid injection, and pain medications 4
• Surgical investigations account for large health care utilization and costs, making it essential to optimize non-surgical management first 5
• Patient education about the role of conservative management versus surgery is critical, as studies show that over 50% of patients have misconceptions about when surgery is indicated, often overestimating the need for surgical intervention 6

Common Pitfalls to Avoid

• Do not proceed directly to fusion surgery without documenting failure of radiofrequency ablation in patients with facet-mediated pain, as this represents premature escalation of care 1, 2
• Ensure proper patient selection by confirming facet joint pain through diagnostic medial branch blocks before performing radiofrequency ablation 1
• Document the specific conservative treatments that have failed before each escalation in the treatment algorithm, as this is essential for justifying medical necessity 3, 4

Relationship to Surgical Decision-Making

If radiofrequency ablation fails to provide adequate relief, this strengthens the case for surgical consideration:

• Documented failure of comprehensive conservative management, including radiofrequency ablation, is a prerequisite for considering decompression or fusion 1, 3
• The presence of lumbar spondylosis alone does not mandate surgery; surgical intervention is reserved for patients who remain totally incapacitated despite exhaustive conservative measures 2
• Fusion is only indicated when there is documented instability, spondylolisthesis, or evidence that extensive decompression will create iatrogenic instability 1