Utilization Review Checklist
Lumbar Denervation and Intradiscal Procedures
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 64635, 64636, 64633, 64634, 22526, 22527. ICD-10 M54.5, M54.50, M54.51, M54.59, M51.36, M54.30.
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 low back pain, with or without radiculopathy
“Indications – Patients with chronic LBP without radiculopathy who failed conservative treatments” — p. 162
Procedures — the guideline treats each separately
Radiofrequency neurotomy, neurotomy or facet rhizotomy for chronic low back pain
Not Recommended. Radiofrequency neurotomy, neurotomy, or facet rhizotomy are not recommended for treatment of patients with chronic LBP, including patients who are confirmed with diagnostic blocks but who do not have radiculopathy and who have failed conservative treatment.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 162
Indications — required:
The guideline advises against this even where diagnostic blocks were positive and conservative treatment failed
“including patients who are confirmed with diagnostic blocks but who do not have radiculopathy and who have failed conservative treatment.” — p. 162
Not recommended — and explicitly including patients confirmed by diagnostic blocks who do not have radiculopathy and who have failed conservative treatment. A positive diagnostic block does not move this request into a supported position; the guideline names that exact case.
Radiofrequency neurotomy, neurotomy or facet rhizotomy for other lumbar spinal conditions
Not Recommended. Radiofrequency neurotomy, neurotomy, or facet rhizotomy are not recommended for treatment of all other lumbar spinal conditions.
Strength of Evidence — Not Recommended, Evidence (C) · confidence low · p. 162
Indications — required:
The guideline advises against this for all other lumbar spinal conditions
“Radiofrequency neurotomy, neurotomy, or facet rhizotomy are not recommended for treatment of all other lumbar spinal conditions.” — p. 162
Not recommended for all other lumbar spinal conditions. The guideline leaves no residual indication.
Radiofrequency lesioning of the dorsal root ganglia for chronic sciatica
Moderately Not Recommended. Radiofrequency lesioning of the dorsal root ganglia is moderately not recommended for treatment of chronic sciatica.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 164
Indications — required:
The guideline moderately advises against dorsal root ganglia lesioning for chronic sciatica
“Radiofrequency lesioning of the dorsal root ganglia is moderately not recommended for treatment of chronic sciatica.” — p. 164
Moderately not recommended on Evidence (B) at Moderate confidence — a stronger negative than the other denervation findings.
Intradiscal electrothermal therapy (IDET)
Not Recommended. IDET is not recommended for treatment of acute, subacute, or chronic low back pain or any other back-related disorder.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 164
Indications — required:
The guideline advises against IDET for low back pain of any duration and for any other back-related disorder
“IDET is not recommended for treatment of acute, subacute, or chronic low back pain or any other back-related disorder.” — p. 164
Not recommended for acute, subacute or chronic low back pain or any other back-related disorder.
Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
Moderately Not Recommended. Percutaneous intradiscal radiofrequency thermocoagulation is moderately not recommended for treatment of acute, subacute, or chronic low back pain particularly including discogenic low back pain.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 165
Indications — required:
The guideline moderately advises against PIRFT, naming discogenic low back pain particularly
“Percutaneous intradiscal radiofrequency thermocoagulation is moderately not recommended for treatment of acute, subacute, or chronic low back pain particularly including discogenic low back pain.” — p. 165
Moderately not recommended, with discogenic low back pain named particularly.
Epidural adhesiolysis (percutaneous lysis of epidural adhesions)
Not Recommended. Adhesiolysis is not recommended for treatment of acute, subacute, or chronic low back pain, arachnoiditis, or spinal stenosis or radicular pain syndromes.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 168
Indications — required:
The guideline advises against adhesiolysis for low back pain, arachnoiditis, spinal stenosis and radicular pain syndromes
“Adhesiolysis is not recommended for treatment of acute, subacute, or chronic low back pain, arachnoiditis, or spinal stenosis or radicular pain syndromes.” — p. 168
Not recommended, and the recommendation names arachnoiditis, spinal stenosis and radicular pain syndromes alongside low back pain — so failed back surgery is not a route around it. The guideline also lists it under its other names: percutaneous lysis of epidural adhesions, epidural neurolysis, epidural decompressive neuroplasty and Racz neurolysis.