Medicare (Traditional Part A & B) · facet joint interventions

.FACETRFAMCARE

Assessment: *** — facet (zygapophyseal) joint-mediated chronic axial *** (cervical /
thoracic / lumbar) pain present >=3 months, moderate-to-severe and functionally limiting,
with pain and disability scales documented at baseline. The pain is predominantly axial
rather than radicular, without untreated radiculopathy or neurogenic claudication and
without another primary pain generator — no fracture, tumor, infection, or significant
deformity on assessment or imaging.

Medical necessity per the Medicare LCD (Facet Joint Interventions for Pain Management):
conservative care has been tried and has failed, or was contraindicated — activity
modification, physical therapy / home exercise, and NSAIDs / analgesics: *** . Two
diagnostic medial branch blocks were performed at the same level(s) *** , each producing
>=80% relief of the index pain for a duration consistent with the anesthetic used, the
second >=2 weeks after the first (*** and ***). Imaging guidance was fluoroscopy or CT;
ultrasound is not covered.

Plan: Medial branch thermal radiofrequency ablation at the confirmed level(s) ***
(64633/64634 cervical-thoracic; 64635/64636 lumbar-sacral), 1-2 levels, to a single spinal
region this session, within <=2 RFA sessions per region per rolling 12 months. [If repeat:]
the prior RFA gave >=50% relief in pain or function for >=6 months. No sedation is planned
[or: moderate sedation is medically necessary because ***]. Risks, benefits, and
alternatives discussed; consent obtained.