CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pulsed Radiofrequency for the Treatment of Chronic Pain

Defines Blue Cross Blue Shield - Rhode Island coverage stance for pulsed radiofrequency (RF) denervation to treat chronic spinal/back pain (facet-related), including coding guidance and relation to commercial and Medicare Advantage products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPulsed Radiofrequency for the Treatment of Chronic Pain

Policy CodePolicy N/A

Change TypeClarified (no material change)

Effective DateFeb 19, 2018

Next Review Date

Key ActionVerify benefits and eligibility in the member's subscriber agreement or employer agreement because benefits may vary and those documents supersede this medical policy.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 01/12/2021; published in multiple provider updates (2017-2021).

Not coveredCoverage status

64999Unlisted CPT required

Commercial & MedicareProduct lines

Coverage Summary

This policy covers Pulsed radiofrequency denervation for chronic spinal/back (facet-related) pain. The policy scope defines Blue Cross Blue Shield - Rhode Island's coverage stance for pulsed RF denervation for chronic spinal/back pain for both Commercial & Medicare Advantage product lines. The high-level coverage stance is not covered / not medically necessary for treatment of chronic spinal/back pain because the evidence is insufficient to determine effects on health outcomes. The policy effective date is 2018-02-19 and the last review date is 2021-01-12. For member-specific benefits and any contract variations, refer to the applicable Benefit Booklet / Evidence of Coverage / Subscriber Agreement.

Not Covered / Experimental Rationale

Pulsed RF is proposed as an alternative to thermal radiofrequency because it delivers short bursts of high-voltage electrical current without heating tissue enough for coagulation; this is thought to reduce tissue heating and theoretically improve safety. However, clinical evidence does not demonstrate that pulsed RF is as effective as conventional thermal radiofrequency denervation. The evidence conclusion is Insufficient evidence to determine the effects of pulsed RF on health outcomes for chronic spinal/back pain, and therefore clinical effectiveness compared with conventional RF is not established. Proposed safety tradeoffs include less tissue heating but a potential for reduced effectiveness compared with conventional thermal RF.

Related Medicare local coverage documents and coding articles referenced by the policy include: LCD L35936: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy; Local Coverage Article 457826: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Coding/Billing); and LCD L33622: Pain Management.

Provider Actions & Billing Impact

Documentation Required

Check member-specific benefits

Verify benefits and eligibility in the member's subscriber agreement or employer agreement because benefits may vary and those documents supersede this medical policy.

Billing Rule

Use unlisted CPT code for pulsed RF

Providers should report pulsed radiofrequency procedures using CPT code 64999 (unlisted procedure, nervous system) as no specific CPT code exists for pulsed RF.

64999

Denial Risk

Services considered not medically necessary

Claims for pulsed radiofrequency denervation for chronic spinal/back pain are at risk for denial as not medically necessary given insufficient evidence.

Background & Evidence Summary

Background: Pulsed RF delivers short bursts of high-voltage electrical current in the radiofrequency range without heating tissue enough to cause coagulation; it is hypothesized to disrupt transmission across small unmyelinated fibers without permanent destruction of nerves. Evidence summary: The policy concludes there is Insufficient evidence to determine the effects of pulsed RF on health outcomes for chronic spinal/back pain, and pulsed RF does not appear to be as effective as conventional radiofrequency denervation. Coding guidance: because there is no specific CPT code for pulsed RF, providers should report the procedure using 64999 (Unlisted procedure, nervous system).

Type	Number	Name
LCD	L35936	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Article	457826	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Coding/Billing)
LCD	L33622	Pain Management