CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pulsed Radiofrequency for the Treatment of Chronic Pain

Defines Blue Cross Blue Shield - Rhode Island coverage position for pulsed radiofrequency (RF) denervation for chronic spinal/back (facet-origin) pain, including coding guidance and evidence summary. Applies to commercial and Medicare Advantage products; benefits may vary by contract.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPulsed Radiofrequency for the Treatment of Chronic Pain

Policy CodePolicy N/A

Change TypeClarified

Effective DateFeb 1, 2002

Next Review Date

Key ActionVerify member-specific benefits, eligibility and applicable coverage in the member's Benefit Booklet/Evidence of Coverage or Subscriber Agreement before providing services; benefits may vary by contract.

SourceLink

POLICY UPDATE CHANGES

Policy statement: pulsed radiofrequency denervation for chronic spinal/back pain is not covered (not medically necessary) due to insufficient evidence.

1Core coverage stance (Not medically necessary)

64999Suggested CPT code listed

Coverage Summary

Defines Blue Cross Blue Shield - Rhode Island coverage position for pulsed radiofrequency (RF) denervation for chronic spinal/back (facet-origin) pain. Policy core position: Not covered / Not medically necessary for chronic spinal/back pain. Evidence blurb: Evidence summary: Insufficient evidence to determine effects of pulsed RF on health outcomes.

Policy dates and scope

Effective Date2002-02-01

Last Review Date2022-01-19

Applies toDefines Blue Cross Blue Shield - Rhode Island coverage position for pulsed radiofrequency (RF) denervation for chronic spinal/back (facet-origin) pain, including coding guidance and evidence summary. Applies to commercial and Medicare Advantage products; benefits may vary by contract.

Coverage StanceNot medically necessary / Not covered (evidence insufficient)

Medical Necessity / Policy Statement

Policy Statement

Pulsed radiofrequency denervation coverage determination:

Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is not covered

Considered not medically necessary; evidence is insufficient to determine effects on health outcomes

Not Covered — Rationale

Rationale for noncoverage: Pulsed RF delivers short bursts of high-voltage current in the radiofrequency range intended to disrupt transmission in small unmyelinated fibers without causing permanent damage. Probe-tip temperatures do not exceed 42°C, unlike thermal RF which reaches temperatures in the 60°C range. Systematic reviews and randomized trials indicate pulsed RF does not appear to be as effective as conventional (thermal) radiofrequency denervation, and the overall evidence is insufficient to establish efficacy for facet denervation; therefore it is considered not medically necessary.

Policy change: Pulsed radiofrequency denervation for chronic spinal/back pain is not covered (not medically necessary) due to insufficient evidence.

Provider Actions & Billing Impact

Documentation Required

Benefit verification

Verify member-specific benefits, eligibility and applicable coverage in the member's Benefit Booklet/Evidence of Coverage or Subscriber Agreement before providing services; benefits may vary by contract.

Billing Rule

Use unlisted CPT for pulsed RF

File CPT 64999 (Unlisted procedure, nervous system) to describe pulsed radiofrequency procedures.

64999

Denial Risk

Claim denial for not medically necessary service

Claims for pulsed radiofrequency denervation may be denied/not covered as not medically necessary because evidence is insufficient to determine effect on health outcomes.

Background & Evidence Summary

Pulsed RF consists of short bursts of electrical current of high voltage in the radiofrequency range delivered without heating tissue sufficiently to cause coagulation. Temperatures at the probe tip do not exceed 42°C, and tissues may cool between pulses. It is postulated that transmission across small unmyelinated nerve fibers is disrupted without permanent damage, while myelinated fibers are not affected.

Evidence summary: Systematic reviews and randomized trials have compared pulsed RF with continuous (thermal) RF and other denervation techniques. The literature indicates pulsed RF does not appear to be as effective as conventional radiofrequency denervation, and the evidence is insufficient to determine effects on health outcomes for facet denervation.

Name	Number	Type
Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy	L35936 / related article 457826	LCD

Revision History

2002-02-01effective

Policy effective date

2022-01-19last_review

Policy last reviewed

clarifiedLatest