Is destruction by neurolytic agent of the paravertebral facet joint nerve (procedure codes 64635 and 64636) medically indicated for an adult patient with a diagnosis of spondylosis without myelopathy or radiculopathy in the lumbosacral region?

Medical Necessity Assessment for Lumbar Facet Nerve Destruction (CPT 64635,64636)

This procedure is NOT medically indicated for this patient based on current high-quality evidence and guidelines. The diagnosis of spondylosis without myelopathy or radiculopathy (M47.817) does not meet the stringent criteria required for facet nerve destruction procedures, and multiple critical prerequisites are absent from the clinical scenario presented.

Why This Procedure Is Not Indicated

Fundamental Diagnostic Requirements Are Missing

The most critical barrier is the absence of confirmed facet-mediated pain through proper diagnostic testing. Before any facet nerve destruction can be considered medically necessary, patients must undergo two separate diagnostic medial branch blocks using the double-injection technique, achieving ≥80% pain relief on both occasions 1, 2, 3. This is not a suggestion—it is a mandatory prerequisite with Grade B recommendation based on Level I evidence 1.

• The double-injection technique uses anesthetics with different durations of action on two separate occasions to confirm that the facet joints are truly the pain generator 2
• A single diagnostic block does not meet guideline standards, and two blocks with ≥80% pain relief threshold are required 3
• Using a pain relief threshold less than 80% does not satisfy evidence-based criteria for predicting radiofrequency ablation success 3

The Diagnosis Code Itself Creates a Problem

Spondylosis without radiculopathy (M47.817) is explicitly a non-specific degenerative condition that does not confirm facet joints as the pain source. The American College of Neurosurgery emphasizes that facet joints are not the primary source of back pain in 90% of patients with degenerative lumbar disease 2. In fact, facet-mediated pain accounts for only 9-42% of patients with degenerative lumbar disease 2.

• No physical examination finding reliably predicts facet-mediated pain, with studies showing no statistically significant association between clinical features and response to facet blocks 2
• Imaging findings of facet arthropathy alone do not justify intervention without adequate conservative management 1
• The presence of spondylosis suggests multiple potential pain generators including disc pathology, which must be ruled out 2

Mandatory Prerequisites That Must Be Met First

Conservative Treatment Requirements

At least 6 weeks of documented conservative treatment failure is required before any interventional procedure can be considered. 1, 3 This is not negotiable according to multiple high-quality guidelines.

The required conservative treatments include:

• Physical therapy with specific exercises targeting lumbar stabilization 3
• Pharmacologic management including NSAIDs or COX-2 inhibitors 4
• Activity modification and potentially bracing 3
• The pain must persist for more than 3 months despite these interventions 1, 2

Clinical Criteria That Must Be Present

Even after conservative treatment failure, specific clinical criteria must be documented: 2

• Symptoms suggestive of facet joint syndrome with absence of radiculopathy (which is met in this case)
• Facet-mediated pain confirmed by provocative testing on physical examination
• No other obvious cause of pain found on imaging studies
• Pain that limits daily activities
• Pain persisting for more than 3 months

Imaging Requirements

Neuroradiologic studies must be negative or fail to confirm disc herniation as the primary pain generator. 3 Imaging must demonstrate "no other obvious cause of pain" before facet interventions can be considered medically necessary 2, 3.

The Correct Diagnostic and Treatment Algorithm

Step 1: Complete Conservative Management (6+ Weeks)

• Physical therapy, NSAIDs, activity modification 3
• Document failure of conservative treatment 1

Step 2: Confirm No Alternative Pain Generators

• MRI to rule out disc pathology, nerve root compression, or other structural causes 2
• Consider sacroiliac joint pathology if pain radiates to hip and buttocks 2
• Evaluate for discogenic pain or annular tears 2

Step 3: First Diagnostic Medial Branch Block

• Perform medial branch block (NOT intra-articular facet injection) with short-acting anesthetic 2
• Document ≥80% pain relief 1, 2
• Document duration of relief 2

Step 4: Second Confirmatory Diagnostic Block

• Perform second medial branch block with different duration anesthetic 2
• Again document ≥80% pain relief 1, 2
• Only if BOTH blocks are positive can you proceed 3

Step 5: Consider Radiofrequency Ablation (NOT Before)

• Only after two positive diagnostic blocks should radiofrequency ablation of medial branch nerves be considered 2, 3
• This is the gold standard treatment for confirmed facet-mediated pain 2, 3

Critical Pitfalls to Avoid

Proceeding directly to facet nerve destruction without diagnostic blocks is the most common and serious error. 1 This approach:

• Violates evidence-based guidelines from multiple societies 1, 2, 3
• Exposes patients to unnecessary procedural risks
• Has extremely low likelihood of benefit (only 7.7% of patients selected for facet procedures based on clinical criteria alone achieve complete relief) 2

Confusing intra-articular facet injections with medial branch blocks is another critical error. 1 The 2025 BMJ guideline on interventional procedures for chronic spine pain found no consistency in recommendations for facet joint injections, and the American College of Neurosurgery provides a Grade B recommendation AGAINST intra-articular facet injections for chronic low back pain from degenerative lumbar disease 5, 1, 3.

Relying on imaging findings alone (such as facet arthropathy on MRI or CT) does not justify the procedure. 1 Incidental findings are extremely common and correlate poorly with symptoms 5.

What About Alternative Procedures?

Intra-articular Facet Steroid Injections

These are explicitly recommended AGAINST by high-quality guidelines. 3 The American College of Neurosurgery provides Level II evidence showing no long-term benefit for intra-articular facet injections in chronic low back pain from degenerative lumbar disease 1, 3.

Epidural Steroid Injections

These are not indicated for non-radicular low back pain from spondylosis without radiculopathy. 3 Epidural injections target radicular pain from nerve root inflammation, which is explicitly absent in this diagnosis code.

Medial Branch Blocks (Therapeutic)

These show better evidence than intra-articular injections but still require proper diagnostic confirmation first. 2 Each medial branch block provides an average of 15 weeks of pain relief, but this is only after facet-mediated pain is confirmed 2.

The Bottom Line

Without documented failure of conservative treatment, without confirmatory diagnostic medial branch blocks showing ≥80% pain relief on two separate occasions, and without imaging ruling out alternative pain generators, proceeding with facet nerve destruction (CPT 64635,64636) is not medically indicated and violates multiple high-quality clinical practice guidelines. 1, 2, 3

The diagnosis code M47.817 (spondylosis without myelopathy or radiculopathy) is a non-specific degenerative condition that does not establish facet joints as the pain source. The proper pathway requires systematic evaluation, conservative treatment, diagnostic confirmation, and only then consideration of therapeutic intervention following the algorithm outlined above.