Radiofrequency Neurolysis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of the enrollee’s mid and lower back pain. Findings: Two physician reviewers found that the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is medical literature supporting the utility of thoracic facet radiofrequency neurolysis for the treatment of pain due to thoracic facet pain. Hegarty performed a 12-month retrospective observational evaluation of adults treated with radiofrequency (RF) for refractory sacroiliac joint syndrome (SIJ).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis/ablation. Review of the literature with comprehensive analysis of the published data pertaining to the effectiveness and risks of fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy for treating chronic neck pain of zygoapophyseal joint origin. The authors concluded that if performed as described in the International Spine Intervention Society guidelines, fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy is effective for cervical zygoapophyseal joint pain and carries only minor risks. This patient complains primarily of severe left-sided neck pain with radiation to the shoulders and head. The provider does not document any evidence of radiculopathy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollee’s recurrent back pain. Findings: Two physician reviewers found that the patient was status post L4/5 microdiscectomy. The treating provider’s report indicated that the patient received one week of pain relief following the caudal and left L5 transforaminal epidural steroid injections. She reported that she also had pain on the right and left lumbar areas with burning and shooting pain down her legs. She felt like her back and legs were going to give out. A lumbar spine examination documented normal alignment and no tenderness to palpation. Range of motion was documented as flexion 90 degrees, extension 15 degrees, and negative straight leg raise at 70 degrees. Lower extremity neurologic examination was reported within normal limits.

A 48-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollee’s chronic pain. Findings: Two physician reviewers found that the patient has chronic low back pain. She is status post posterior lumbar fusion at L4-5 and intrathecal pump placement for chronic low back pain. The patient’s medications include oxycodone, Baclofen, and intrathecal bupivacaine. Sacroiliac joint injections were performed, which reportedly resulted in more than 50% reduction in her pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Radiofrequency Neurolysis, then check the rights and deadlines that apply to your plan.