CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Pulsed radiofrequency facet denervation for chronic spinal/back pain

Defines Blue Cross Blue Shield of Rhode Island coverage stance for pulsed radiofrequency (RF) facet denervation for treatment of chronic spinal/back pain for Commercial and Medicare products, including coding guidance and rationale.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPulsed radiofrequency facet denervation for chronic spinal/back pain

Policy CodePolicy N/A

Change TypeClarified codingstance unchanged

Effective DateFeb 19, 2018

Next Review Date

Key ActionClaims for pulsed radiofrequency denervation for chronic spinal/back pain are subject to denial because the technology is considered not covered for Medicare members and not medically necessary for commercial products due to insufficient evidence.

SourceLink

POLICY UPDATE CHANGES

Policy states pulsed radiofrequency denervation is not covered for Medicare and considered not medically necessary for commercial products due to insufficient evidence.

0Covered Indications

64999Suggested Unlisted CPT Code

Coverage Summary

Coverage summary: Pulsed radiofrequency (RF) facet denervation is not covered / not medically necessary for the treatment of chronic spinal/back pain — not covered for BlueCHiP for Medicare and not medically necessary for Commercial products. Evidence conclusion: Insufficient to determine the effects of pulsed RF denervation on health outcomes.

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Medical-Necessity / Coverage Determinations

Coverage Determination

Pulsed radiofrequency denervation is covered only when criteria are met; policy statements below reflect determination:

ALL of the following

BlueCHiP for Medicare: Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products: Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Medical Criteria

Medical criteria section:

ALL of the following

Medical Criteria: Not applicable
Prior Authorization: Not applicable

Coding Guidance

Suggested billing (unlisted code)CPT

64999

Unlisted procedure, nervous system (providers should file using this unlisted code for pulsed radiofrequency)

Operational note (coding guidance): The document instructs providers to file pulsed radiofrequency procedures using the unlisted CPT code 64999 because there are no specific CPT codes for pulsed RF; this coding guidance is included alongside the coverage determination as an operational billing rule.

Provider Actions / Operational Notes

Documentation Required

Diagnostic confirmation

Diagnosis of facet joint pain is confirmed by response to nerve blocks; documentation of diagnostic nerve block response is part of clinical background though no medical-necessity criteria are specified.

Billing Rule

Use unlisted CPT for billing

At this time there are no specific CPT codes to describe pulsed radiofrequency; providers should file using CPT 64999 (Unlisted procedure, nervous system).

64999

Denial Risk

Not covered / Not medically necessary

Claims for pulsed radiofrequency denervation for chronic spinal/back pain are subject to denial because the technology is considered not covered for Medicare members and not medically necessary for commercial products due to insufficient evidence.

Background & Definitions

Background: Pulsed RF delivers short bursts of high-voltage electrical current in the radiofrequency range without heating tissue enough to cause coagulation (probe tip temperatures ≤ 42°C), proposed as a possibly safer alternative to thermal RF. However, tissues may cool between pulses, and pulsed RF does not appear to be as effective as conventional radiofrequency denervation; evidence is insufficient to evaluate other denervation methods and to determine effects on health outcomes.

Definition: Pulsed radiofrequency (RF) denervation — a procedure using short bursts of high-voltage electrical current in the radiofrequency range that does not heat tissue enough to cause coagulation, intended to provide long-term pain relief for facet joint pain.

Evidence conclusion: Insufficient to determine effects of pulsed RF denervation on health outcomes.

Type	Number	Name
LCD	L35936	Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
LCD	L33622	Pain Management

Revision History

2018-02-19effective_date

Policy effective date.

2019-01-15last_reviewLatest

Policy last updated/reviewed.

2018-02-19coverage_determination

BlueCHiP for Medicare: Pulsed radiofrequency denervation for chronic spinal/back pain is not covered because evidence is insufficient to determine effects on health outcomes.

2018-02-19coverage_determination

Commercial Products: Pulsed radiofrequency denervation for chronic spinal/back pain is considered not medically necessary because evidence is insufficient to determine effects on health outcomes.

2018-02-19clarification

Policy states pulsed radiofrequency denervation is not covered for Medicare and considered not medically necessary for commercial products due to insufficient evidence; includes coding guidance to bill with CPT 64999.