CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Neurotomy Authorization Request Form (coverage criteria)

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This form governs prior authorization submission requirements for radiofrequency and other neurotomy procedures for BlueCross BlueShield of Tennessee commercial members. It specifies required clinical and administrative information providers must submit to request authorization for CPT codes listed.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPain Management Neurotomy Authorization Request Form (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with relevant medical records including imaging, office visit notes, diagnostic nerve block results, prior neurotomy history, and planned procedure details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4document chunks

4 codes

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Neurotomy Authorization Request Form (coverage criteria)

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Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPain Management Neurotomy Authorization Request Form (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes in this revision.

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4document chunks

4 codes

Coverage and Authorization Criteria

Information required for medical necessity review

Authorization review will consider documentation meeting the following information elements

Authorization submission requirements: Provider must submit completed form with: requested procedure code and modifier, spine level and region, primary and additional diagnosis codes, anticipated date of service, planned intervention type, diagnostic nerve block result (percent relief and timing), prior neurotomy history (dates, levels, number in past 6 months, result and duration), patient anthropometrics (height, weight, BMI), facility/provider identifiers (BCBSTN Provider ID, facility TIN, facility NPI), and site of service.

These items are requested on the form and are required for medical necessity review.

Frequency and recent procedure checks

Utilization constraints explicitly queried on form

Prior procedure frequency checks: Has a previous radiofrequency neurotomy been performed at this joint within 6 months? How many neurotomy procedures has the patient had at this joint in the past 6 months? Have there been more than two (2) thermal radiofrequency sessions during the calendar year in the spinal region intended to be treated?>2 sessions per calendar year; 6 months look-back

Responses will inform coverage determination or frequency-limit review; dates and levels of all previous radiofrequency sessions are requested.

This authorization form applies to BlueCross BlueShield of Tennessee commercial members only. It is used to request prior authorization for the CPT codes listed on the form and does not apply to other member types or benefit lines.

The form explicitly queries recent procedure frequency to support utilization review: it asks whether a previous radiofrequency neurotomy was performed at the same joint within 6 months, requests the number of neurotomy procedures at that joint in the past 6 months, and asks for dates and levels of all prior radiofrequency sessions. Additionally, the form asks whether there have been more than two (2) thermal radiofrequency sessions during the calendar year in the spinal region intended to be treated (cervical/thoracic, lumbar, or sacroiliac). Responses to these items inform coverage determination and may trigger frequency-limit review or denial if thresholds are exceeded.

Coding and Look-back Intervals

CPT codes referencedCPT

64633	Described on form as a CPT code to use with this authorization
64634	Described on form as a CPT code to use with this authorization; use LT/RT modifiers only, not 50
64635	Described on form as a CPT code to use with this authorization
64636	Described on form as a CPT code to use with this authorization; use LT/RT modifiers only, not 50

Previous neurotomy look-back

Look-back interval6 months (form asks if a previous radiofrequency neurotomy was performed at this joint within 6 months)

Count captureForm asks: 'How many neurotomy procedures has the patient had at this joint in the past 6 months?'

Result documentationForm requests result of prior procedures: 'Reduction in pain by _____ % for a duration of _____ months.'

Provider Submission Requirements and Actions

Prior Authorization

Prior authorization required for CPT 64633–64636

Prior authorization is required for CPT codes 64633, 64634, 64635, and 64636 for BlueCross BlueShield of Tennessee commercial members; submit the completed neurotomy authorization form to request approval before procedure scheduling.

Use this form for CPT codes 64633, 64634, 64635, 64636
Codes 64634 and 64636 require LT and/or RT modifiers only (not 50)

Step Therapy

Document conservative therapy and diagnostic block results

Document prior conservative treatments and the results of diagnostic nerve blocks on the submission: record the percent pain relief achieved and the timing since the diagnostic injection.

Select percent pain relief category for diagnostic nerve block (No block, 0–19%, 20–39%, 40–59%, 60–79%, 80–100%)
Indicate time since diagnostic injection (less than 1 week, 1 week, 2 weeks, 3+ weeks)

Documentation of Prior Conservative Treatments

Document prior conservative treatments in submission

Document prior conservative treatments and diagnostic block results in the submission

Conservative treatments and diagnostic block documentation: Document prior conservative therapies attempted (as applicable) and include clinical notes showing failure or intolerance. Provide diagnostic nerve block result with percent pain relief and time since the diagnostic injection. If no diagnostic block was completed, indicate this on the form.

The form requests prior conservative treatment documentation and diagnostic block details (percent relief and timing) to support medical necessity review.

Frequency and Interval Limits for Neurotomy

Thermal radiofrequency neurotomy (spinal region) frequency check

Calendar-year session limitForm queries whether there have been more than two (2) thermal radiofrequency sessions during the calendar year in the spinal region intended to be treated; exceeding >2 may be flagged/limited

Regions queriedCervical/Thoracic, Lumbar, Sacroiliac (form asks which spinal region is intended to be treated)

Documentation requiredDates and Levels of All Previous Radiofrequency Sessions must be provided on the form

Radiofrequency neurotomy prior-procedure query

6-month prior procedure queryForm asks: 'Has a previous radiofrequency neurotomy been performed at this joint within 6 months?' and includes response options

Previous session details

Procedure Types and Diagnostic Response Options

Types of intervention planned

Non-pulsed RFNon-pulsed radiofrequency denervation (listed on form)

Pulsed RFPulsed radiofrequency denervation (listed on form)

LaserLaser denervation (listed on form)

ChemicalChemical denervation (via alcohol, phenol, or high-concentration local anesthetic) (listed on form)

Other optionsCryo-denervation; Low grade thermal energy (<80 degrees Celsius) (listed on form)

Diagnostic nerve block response

Pain relief categories

Imaging and Supporting Studies

Documentation Required

Include relevant imaging with neurotomy authorization

When applicable, include pertinent imaging studies as part of the authorization package; the form requests submission of imaging where relevant to support the neurotomy request.

Attach relevant imaging that supports the diagnosis and planned spinal region for treatment

Background

This form is used to request authorization for neurotomy procedures (radiofrequency and other denervation techniques) to treat spinal-region pain. It collects the planned procedure and targeted spinal region, the type of denervation to be performed, diagnostic nerve block response (percent pain relief and timing), prior neurotomy history (including dates, levels, results and duration of benefit), and supporting clinical documentation to evaluate medical necessity.