Wiki Radiofrequency CPT 64633


Pittsboro, NC
Best answers
According to Medicare guidelines for CPT 64633, destruction of neurolytic agent, there is a limit of 2 levels unilaterally or bilaterally at the same level within a 12 month period of time. Does that mean more no more than two sessions or no more than two levels?

For example...

Our doctor performed CPT 64633 on levels C3 and C4, one month later she performed it at C5 abd C6, one month later she performed C1 and C2.

Medicare is denying the C1 and C2 as more than two sessions even though C1 and C2 was only treated once.

I hope this makes sense. Any feedback will be much appreciated. Im doing a review and want to know the best way to appeal it.
Does that mean more no more than two sessions or no more than two levels?

I believe you will see in certain LCDs they state the treatment should last six months and they don't feel it is medically necessary to repeat the procedure before six months has transpired, which limit to procedures a year. There can also be describe for the facet blocks they don't feel treatment of more than three levels is medical necessity. If they feel the facet nerve denervation should be performed at the same level the patient had benefit from the facet blocks than it would be hard to exceed three levels with the radiofrequency. Although I have seen where for example 4 levels is performed and don't see a denial based on the LCD policy. I believe the most effective is having the provider write a supporting letter to go with the procedure note which describes the last couple of dates of service with the patient and what was provided for the patient. What current imaging results are and what were the indications to proceed with the procedures. The patient's response, why only two levels were performed per encounter.

Below is an example from WPS Medicare J5 Local Coverage Determination policy

"Multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. It is reasonable to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first procedure fails to produce the desired effect or rules out the diagnosis, the provider may proceed to the next logical test or treatment if desired.

Accordingly, providing a combination of epidural block, facet joint blocks, bilateral sacroiliac joint injections, lumbar sympathetic blocks or providing more than three levels of facet joint blocks to a patient on the same day is considered not reasonable or necessary. Such therapy can lead to an improper diagnosis or unnecessary treatment."

Facet Joint Denervation:

If the patient gets sufficient relief of pain from a facet joint block for a meaningful period of time but the pain recurs, one of the options is to denervate the facet joint. This procedure requires placement of a needle in the facet joint under fluoroscopic or CT guidance, injection of a local anesthetic agent, and if the pain is relieved (confirming that the needle is in the area desired to be denervated), injection of a neurolytic agent to destroy the facet joint nerve. This denervation can also be achieved by passing an electric current through a similarly placed electrode, by applying heat or by using radiofrequency.

When facet joint block has been effective in managing the back pain under consideration, then a permanent denervation may be considered, but should be restricted only to the level or levels that, from the results of the blocks, can be reasonably considered the source of the pain. This may not include all the levels that were blocked.

CPT codes mentioned in this policy may not be used to treat patients with acupuncture techniques or variations of those techniques.

The effects of denervation should last from six months to one year or longer. In some instances the effects may be permanent. Repeat denervation procedures at the same joint/nerve level will only be considered medically necessary when the patient has had significant improvement of pain after the initial facet joint nerve destruction that lasted an appropriate period of time (greater than or equal to six months.)