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    v1.0.28
    OpenPayerPolicy UpdatesPain ManagementAmbetter Nevada Sacroiliac Policy Update | OpenPay…
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    CurrentAmbetter NevadaPolicy WA.CP.MP.166

    Sacroiliac Joint Interventions for Pain Management

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    This policy addresses coverage for sacroiliac joint nerve blocks and conventional, cooled, and pulsed radiofrequency neurotomy. Sacroiliac joint injections are managed by Evolent under separate policy ECG_1756.

    Policy Summary
    PayerAmbetter Nevada
    PolicySacroiliac Joint Interventions for Pain Management
    Policy CodePolicy WA.CP.MP.166
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionFor sacroiliac joint injections, use Evolent's criteria in policy ECG_1756.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Intervention categories not medically necessary
    2CPT codes not supporting coverage criteria
    3Radiofrequency neurotomy techniques addressed

    Sacroiliac Joint Intervention Coverage

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Sacroiliac Nerve Blocks

    Considered not medically necessary because effectiveness has not been established.

    Sacroiliac nerve blocks are considered not medically necessary because effectiveness has not been established.

    Conventional, Cooled, and Pulsed SIJ Radiofrequency Neurotomy

    Considered not medically necessary because effectiveness has not been established.

    Sacroiliac radiofrequency neurotomy: Radiofrequency neurotomy of the sacroiliac joint, including conventional, cooled, and pulsed techniques, is considered not medically necessary because effectiveness has not been established.

    High-quality studies are lacking for conventional and pulsed radiofrequency neurotomy; additional well-designed studies are needed for cooled radiofrequency neurotomy.

    Sacroiliac nerve blocks are excluded as not medically necessary because effectiveness has not been established.

    Conventional, cooled, and pulsed radiofrequency neurotomy of the sacroiliac joint is excluded as not medically necessary because effectiveness has not been established. High-quality studies are lacking for conventional and pulsed techniques, and additional well-designed studies are needed to evaluate cooled radiofrequency neurotomy.

    Sacroiliac nerve blocks are considered not medically necessary because effectiveness has not been established.

    Conventional, cooled, and pulsed radiofrequency neurotomy of the sacroiliac joint are considered not medically necessary because effectiveness has not been established.

    Codes That Do Not Support Coverage

    CPT codes that do not support coverage criteriaCPTNot Covered
    64451Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography).
    64625Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography).

    Provider Guidance

    Prior Authorization

    Use Evolent criteria for SIJ injections

    For sacroiliac joint injections, use Evolent’s criteria in policy ECG_1756. These services are managed by Evolent and are not governed by the criteria in this policy.

    Denial Risk

    Sacroiliac nerve blocks are not medically necessary

    Sacroiliac nerve blocks are considered not medically necessary because effectiveness has not been established.

    Denial Risk

    SIJ radiofrequency neurotomy is not medically necessary

    Radiofrequency neurotomy of the sacroiliac joint—including conventional, cooled, and pulsed techniques—is considered not medically necessary because effectiveness has not been established. High-quality studies are lacking for conventional and pulsed techniques, and additional well-designed studies are needed to evaluate cooled radiofrequency neurotomy.

    Clinical Background

    Sacroiliac joint pain and dysfunction are usually treated conservatively with nonsurgical pain-relief measures. When conservative therapy fails, a sacroiliac joint injection may have diagnostic and therapeutic uses; however, injections are managed under a separate Evolent policy. This policy considers sacroiliac nerve blocks and radiofrequency neurotomy not medically necessary because effectiveness has not been established.

    Radiofrequency Neurotomy

    Radiofrequency neurotomy
    Radiofrequency denervationUses radiofrequency energy to stop the transmission of pain signals to the central nervous system.
    Radiofrequency ablation (RFA)Another name for radiofrequency denervation; it uses radiofrequency energy to stop the transmission of pain signals to the central nervous system.
    Radiofrequency neurotomyAnother name for radiofrequency denervation; it uses radiofrequency energy to stop the transmission of pain signals to the central nervous system.

    Conservative Therapy Context

    Image Guidance

    Note

    Image guidance is included in the CPT descriptions

    CPT 64451 and CPT 64625 include image guidance in their descriptions: fluoroscopy or computed tomography. This policy does not separately establish an authorization requirement for the image guidance.

    • CPT 64451: injection of anesthetic agent(s) and/or steroid to nerves innervating the sacroiliac joint, with image guidance.
    • CPT 64625: radiofrequency ablation of nerves innervating the sacroiliac joint, with image guidance.

    Excluded Services

    The following services are not covered: sacroiliac nerve blocks; conventional radiofrequency neurotomy of the sacroiliac joint; cooled radiofrequency neurotomy of the sacroiliac joint; and pulsed radiofrequency neurotomy of the sacroiliac joint.

    Policy Summary
    PayerAmbetter Nevada
    PolicySacroiliac Joint Interventions for Pain Management
    Policy CodePolicy WA.CP.MP.166
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionFor sacroiliac joint injections, use Evolent's criteria in policy ECG_1756.
    SourceLink
    On This Page
    Sacroiliac Joint Intervention CoverageCodes That Do Not Support CoverageProvider GuidanceClinical BackgroundRadiofrequency NeurotomyConservative Therapy ContextImage GuidanceExcluded Services