Utilization Review Checklist
Cervicothoracic Radiofrequency Neurotomy and Facet Rhizotomy
Derived from the ACOEM Cervical and Thoracic Spine Disorders Guideline, edition 17 October 2018, as adopted into the California MTUS 18 April 2019. CPT 64633, 64634, 64635, 64636. ICD-10 M54.2, M53.82, G44.86, M47.812.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis(informational — not scored)
Required
Chronic cervicothoracic pain or cervicogenic headache
“There is no recommendation for or against the use of radiofrequency neurotomy, neurotomy, or facet rhizotomy for the treatment of chronic cervicothoracic pain confirmed with diagnostic blocks, but who do not have radiculopathy and who have failed conservative treatment.” — p. 100
Procedures — the guideline treats each separately
Radiofrequency neurotomy, neurotomy or facet rhizotomy for chronic cervicothoracic pain
No Recommendation. There is no recommendation for or against the use of radiofrequency neurotomy, neurotomy, or facet rhizotomy for the treatment of chronic cervicothoracic pain confirmed with diagnostic blocks, but who do not have radiculopathy and who have failed conservative treatment.
Strength of Evidence — No Recommendation, Insuffcient Evidence (I) · confidence low · p. 100
Indications — required:
The guideline makes no recommendation for or against this
“There is no recommendation for or against the use of radiofrequency neurotomy, neurotomy, or facet rhizotomy for the treatment of chronic cervicothoracic pain confirmed with diagnostic blocks, but who do not have radiculopathy and who have failed conservative treatment.” — p. 100
No recommendation either way — the guideline is neutral, which is NOT approval and NOT denial. The description covers pain confirmed with diagnostic blocks in patients without radiculopathy who have failed conservative treatment: the standard case. The Low Back chapter reaches a NEGATIVE conclusion on the same procedure lumbar-side, so do not carry either answer across.
Radiofrequency neurotomy for cervicogenic headache
Moderately Not Recommended. Radiofrequency neurotomy is moderately not recommended for the treatment of cervicogenic headache.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence low · p. 100
Indications — required:
The guideline moderately advises against radiofrequency neurotomy for cervicogenic headache
“Radiofrequency neurotomy is moderately not recommended for the treatment of cervicogenic headache.” — p. 100
Moderately not recommended on Evidence (B) — a clear negative, unlike the neutral position on cervicothoracic pain.