CurrentCignaPolicy 0525

Peripheral nerve destruction/ablation (radiofrequency, cryoablation, chemical, laser, electrical) — Coverage Policy

Defines medical necessity and coverage for peripheral nerve destruction/ablation techniques (e.g., radiofrequency, cryoablation, glycerol rhizotomy) for various pain conditions for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyPeripheral nerve destruction/ablation coverage (radiofrequency, cryoablation, chemical, laser, electrical)

Policy CodePolicy 0525

Change TypeFocused review (policy statement added)

Effective DateN/A

Next Review DateN/A

Key ActionDocument prior conservative therapy failure (e.g., 6-12 months where specified) and include covered diagnosis/procedure codes when submitting for coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added policy statement for percutaneous cryoablation of the lower extremities.

Annual review with no policy statement changes recorded.

trigeminal neuralgiaMedically necessary example

cryoablation (LE)Investigational example

limited RCTsRCT availability

≈80Excluded ICD-10 count

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Coverage Criteria and Policy Statements

Trigeminal Neuralgia (Medically Necessary)

Covered when ALL of the following are met

Trigeminal neuralgia - medically necessary: Peripheral nerve destruction using radiofrequency ablation or glycerol rhizotomy is considered medically necessary for treatment of trigeminal neuralgia refractory to other alternative treatments (e.g., medication, microdecompression).refractory to other alternative treatments

Applies when medication and/or invasive alternatives (such as microdecompression) have failed; evidence primarily for percutaneous RF or glycerol rhizotomy.

Percutaneous Cryoablation (Investigational)

Percutaneous cryoablation - investigational: Percutaneous cryoablation of distal/peripheral nerves in the lower extremities is considered experimental, investigational, or unproven.

Codes 0441T, C9808, C9809 are listed as experimental/investigational in this policy.

Not Covered Indications

Not covered for ANY of the following conditions

Not covered indications: Peripheral nerve destruction (cryoablation, laser, electrical, chemical or radiofrequency) is not covered or reimbursable for treatment of sacroiliac joint pain; knee pain; hip pain; shoulder pain; foot/heel pain; headache; occipital neuralgia; intercostal neuralgia; or lower extremity pain resulting from complex regional pain syndrome, peripheral nerve entrapment/compression (e.g., tarsal tunnel syndrome, sciatica), or peripheral neuropathy.

Explicit exclusions listed in the coverage policy.

Coverage summary by indication

Coverage stance varies by indication based on available evidence:

Knee osteoarthritis - genicular nerve RFA: Some randomized trials and meta-analyses report short-term improvement in pain and function for genicular (genicular) nerve radiofrequency ablation in knee osteoarthritis; evidence is limited by small trials and heterogeneity.Conservative therapy should be attempted prior to procedure

Short-term benefit reported but long-term effectiveness uncertain; prior conservative care expected.

Sacroiliac (SI) joint RF ablation: Clinical effectiveness and duration of effect of SI joint RF ablation has not been consistently demonstrated; evidence is limited and insufficient to establish safety and efficacy for broad coverage.Failed conservative therapy

RCTs limited, small samples, short follow-up; other ablative modalities for SI joint also lack sufficient evidence.

Foot procedures (plantar fasciitis, Morton's neuroma):

Coverage with clinical criteria and evidence limitations

Coverage is conditional and depends on indication-specific evidence plus prior conservative therapy:

General requirement: Other treatment modalities should be attempted before considering ablative techniques.N/A

Based on professional society guidance (ASA Task Force, ASIPP, ASRN/ASRA); chemical denervation not recommended routinely.

Supported but limited indications: Radiofrequency neurotomy may be used for certain targets (cervical medial branch, lateral sacral branch, genicular nerve, hip obturator/femoral branches, occipital nerve) per ASPN consensus, but evidence is variable and limited.N/A

Use is conditional; studies limited by heterogeneity, small samples, and short follow-up.

Knee OA specifics: Studies show some short-term pain and function improvement for cooled and conventional RF of genicular nerves after failed conservative care, but long-term effectiveness is uncertain.

Medically Necessary — Neurolytic lesion/destruction when applicable policy statements are met

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

Medically necessary neurolytic codes: Use of specified CPT codes (61790, 61791, 64600, 64605, 64610) is considered medically necessary when the applicable clinical criteria for trigeminal neuralgia or other approved indications are satisfied.Applicable policy clinical criteria met

Refer to the applicable coverage statements for clinical criteria (e.g., refractory trigeminal neuralgia).

Experimental/Investigational

Considered Experimental/Investigational/Unproven when used for the treatment of pain conditions as outlined in the above coverage policy statement:

Experimental device/cryo codes: Codes 0441T, C9808, and C9809 (percutaneous cryoablation and associated device/consumable HCPCS) are considered experimental, investigational, or unproven for treatment of pain conditions in this policy.

C9808/C9809 note qualifying Medicare nonopioid device requirements but remain listed as experimental in this policy excerpt.

Not Medically Necessary / Not Covered

Not Covered or Reimbursable when used for the treatment of pain conditions as outlined in the above coverage policy statement:

Not covered procedures and diagnoses: A broad list of CPT codes (e.g., 64624, 64632, 64640) and numerous ICD-10 diagnosis codes (see policy lists) are explicitly designated Not Covered or Not Reimbursable when used to treat pain conditions.

Presence of these procedure or diagnosis codes as the indication for pain-related treatment supports denial of coverage.

Not Covered Diagnoses

Diagnoses Not Covered

Not Covered Diagnoses: All ICD-10 codes listed in the policy (chunks 72–94) are designated Not Covered or Not Reimbursable when used as the primary diagnosis to support radiofrequency or related neuroablative procedures for pain treatment.

Refer to the policy's listed ICD-10 code groups for the full set of excluded diagnoses.

Not Covered — Diagnosis exclusions (expanded list)

Not Covered or Reimbursable when used for the treatment of pain conditions as outlined in the above coverage policy statement:

Excluded diagnosis list (expanded): Any of the listed ICD-10 diagnosis codes (including bursopathies, tendinopathies, osteoarthritis groups, spine-related codes, trauma/symptom codes, and presence of artificial joint codes) render radiofrequency and related neuroablative procedures Not Covered when billed for pain treatment.

These exclusions cover a wide range of musculoskeletal, neuropathic, and headache diagnoses enumerated in the policy lists.

This policy addresses peripheral nerve destruction techniques (including radiofrequency, cryoablation, chemical, laser and electrical methods) and defines coverage boundaries by indication. Peripheral nerve destruction is considered medically necessary for trigeminal neuralgia when refractory to other treatments (e.g., medication or microdecompression). For most other pain indications the policy restricts coverage: procedures are not covered or reimbursable for sacroiliac joint pain, knee, hip, shoulder, foot/heel pain, headache/occipital neuralgia, intercostal neuralgia, and lower-extremity pain due to CRPS, peripheral nerve entrapment/compression, or peripheral neuropathy unless an explicit medically necessary statement exists in the policy.

Neuroablative treatments for peripheral neuromas (for example, Morton's neuroma) and some techniques applied to the sacroiliac (SI) joint are considered investigational or lacking sufficient evidence. The literature for peripheral neuroma ablation (alcohol injections, RF, cryo) is limited to case series and small studies and is described in the policy as research/unproven. Similarly, SI joint RF ablation and other ablative modalities (laser, chemical, electrical) have inconsistent and limited RCT evidence and therefore do not meet the policy’s threshold for routine coverage.

Peripheral nerve destruction for other pain conditions — including intercostal neuralgia, complex regional pain syndrome (CRPS), peripheral nerve compression/entrapment (e.g., tarsal tunnel, sciatica), peripheral neuropathic conditions, craniofacial pain, post-herpetic neuralgia, post-amputation pain and post-herniorrhaphy pain — is not supported by sufficient peer-reviewed evidence. The policy states that published reports are scarce, predominantly case series or small trials, and therefore those applications are considered not medically necessary or investigational.

Certain procedure and diagnosis codes are explicitly identified as Not Covered or listed under the experimental/ investigational or medically necessary groupings. Examples include CPT codes such as 64624, 64632, 64640 (listed as Not Covered) and trigeminal neurolytic codes 61790, 61791, 64600, 64605, 64610 (listed as considered medically necessary when criteria are met). Device and cryoablation codes 0441T, C9808, C9809 are designated experimental/investigational in this policy excerpt.

The policy enumerates numerous ICD-10 codes that are designated Not Covered/Not Reimbursable when used to support pain-related neuroablative procedures. The document lists musculoskeletal, bursopathy, arthropathy, spine-related and symptom/trauma codes (see the Not Covered ICD-10 lists in the policy for the full enumeration) that will render a service Not Covered when billed as the indication for neuroablative treatments.

Use of radiofrequency or related neuroablative procedures is explicitly Not Covered when any of the listed ICD-10 diagnosis codes are submitted as the indication. The policy notes that presence of these excluded diagnosis codes on claims or prior authorization requests supports denial of coverage for neuroablative procedures.

A focused review on 12/3/2023 added a policy statement specific to percutaneous cryoablation of the lower extremities; annual reviews in 2024 and 2025 noted no other policy statement changes. Providers should note this revision when requesting coverage for lower-extremity cryoablation procedures.

Percutaneous cryoablation of distal/peripheral nerves in the lower extremities is considered experimental, investigational, or unproven and therefore not medically necessary according to the policy excerpt. Associated CPT/HCPCS device codes (e.g., 0441T, C9808, C9809) are listed as experimental in this policy.

Ablative modalities that lack demonstrated safety and efficacy in peer-reviewed literature — including some radiofrequency approaches for the SI joint and chemical ablation techniques for neuromas — are identified as not supported by sufficient evidence and are therefore considered investigational or not medically necessary for routine care.

The policy indicates that ablative techniques for cervicogenic headache and occipital neuralgia are unsupported by consistent high-quality evidence. Randomized trials and systematic reviews have not demonstrated reliable benefit, and peripheral nerve ablation for these headache syndromes is not considered established coverage.

The policy lists a range of procedures and diagnoses as Not Covered or Not Reimbursable when used to treat pain conditions. Examples include neurolytic destruction of genicular nerve branches (64624), plantar digital nerve neurolysis (64632), and many peripheral nerve and musculoskeletal ICD-10 diagnoses; claims using these codes as the pain indication may be denied.

Enumerated ICD-10 codes across the Not Covered lists (including bursopathies, tendinopathies, arthropathies, spine and soft-tissue diagnoses) are considered not medically necessary when used to justify neuroablative pain treatments. Providers should verify diagnosis coding against the policy’s Not Covered ICD-10 listings prior to submission.

Procedures billed for bursopathies, tendinopathies, spur/enthesopathy conditions and specific shoulder, hip, knee, ankle and foot diagnoses (as enumerated in the policy) are listed as Not Covered when used as the indication for neuroablative treatments. The policy gives extensive ICD-10 examples (see chunks 90–94) that will not support coverage for ablation procedures.

Procedure and Diagnosis Codes

Medicare NCD/LCD Referencesmixed

NCD 160.1	Induced Lesions of Nerve Tracts (National Coverage Determination)
LCD L39455	Sacroiliac Joint Injections and Procedures (NGS)
LCD L34076	Injections - Tendon, Ligament, Ganglion Cyst, Tunnel SyndROMES and MORTON's Neuroma (Noridian)
LCD L34218	Injections - Tendon, Ligament, Ganglion Cyst, Tunnel SyndROMES and MORTON's Neuroma (Noridian)

Considered Medically Necessary CPT CodesCPTCovered

61790	Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion.
61791	Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract.
64600	Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch.
64605	Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale.
64610	Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring

Considered Experimental/Investigational/UnprovenCPT|HCPCSExperimental

0441T	Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
C9808	Nerve cryoablation probe (e.g., cryoICE, cryoSPHERE, cryoSPHERE MAX, cryo2), including probe and all disposable system components, nonopioid medical device
C9809	Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, nonopioid medical device

Not Covered Procedure/Procedure-Related CodesmixedNot Covered

64624	Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed.
64632	Destruction by neurolytic agent, plantar common digital nerve.
64640	Destruction by neurolytic agent; other peripheral nerve or branch

Not Covered ICD-10 Codes (selection) - mixed groupsICD-10Not Covered

G43.001	Migraine without aura, not intractable, with status migrainosus.
G43.009	Migraine without aura, not intractable, without status migrainosus.
G43.011	Migraine without aura, intractable, with status migrainosus.
G43.019	Migraine without aura, intractable, without status migrainosus.
G43.101	Migraine with aura, not intractable, with status migrainosus.
G43.109	Migraine with aura, not intractable, without status migrainosus.
G43.111	Migraine with aura, intractable, with status migrainosus.
G43.119	Migraine with aura, intractable, without status migrainosus.
G44.001-G44.89	Other headache syndromes.
G54.1	Lumbosacral plexus disorders.

Not Covered ICD-10 Codes (peripheral neuropathy/CRPS etc.)ICD-10Not Covered

G57.00	Lesion of sciatic nerve, unspecified lower limb.
G57.01	Lesion of sciatic nerve, right lower limb.
G57.02	Lesion of sciatic nerve, left lower limb.
G57.03	Lesion of sciatic nerve, bilateral lower limbs.
G57.10	Meralgia paresthetica, unspecified lower limb.
G57.30	Lesion of lateral popliteal nerve, unspecified lower limb.
G57.50	Tarsal tunnel syndrome, unspecified lower limb.
G57.60	Lesion of plantar nerve, unspecified lower limb.
G57.70	Causalgia of unspecified lower limb.
G58.0	Intercostal neuropathy.

Not Covered ICD-10 Codes (selected musculoskeletal groups)ICD-10Not Covered

M71.21	Synovial cyst of popliteal space [Baker], right knee.
M71.22	Synovial cyst of popliteal space [Baker], left knee.
M71.311	Other bursal cyst, right shoulder.
M71.312	Other bursal cyst, left shoulder.
M71.319	Other bursal cyst, unspecified shoulder.
M71.351	Other bursal cyst, right hip.
M71.352	Other bursal cyst, left hip.
M71.359	Other bursal cyst, unspecified hip.

Not Covered ICD-10 Codes (spine-related)ICD-10Not Covered

M48.07	Spinal stenosis, lumbosacral region
M50.20	Other cervical disc displacement, unspecified cervical region
M51.17	Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.370	Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only
M54.51	Vertebrogenic low back pain

Not Covered ICD-10 Codes (soft tissue and bursopathies)ICD-10Not Covered

M67.811	Other specified disorders of synovium, right shoulder
M70.61	Trochanteric bursitis, right hip
M71.21	Synovial cyst of popliteal space [Baker], right knee
M75.01	Adhesive capsulitis of right shoulder
M75.101	Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic

Not Covered ICD-10 Codes (selection from list)ICD-10Not Covered

M06.069	Rheumatoid arthritis without rheumatoid factor, unspecified knee
M06.072	Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M07.611	Enteropathic arthropathies, right shoulder
M07.612	Enteropathic arthropathies, left shoulder
M07.619	Enteropathic arthropathies, unspecified shoulder
M07.651	Enteropathic arthropathies, right hip
M07.652	Enteropathic arthropathies, left hip
M07.659	Enteropathic arthropathies, unspecified hip
M07.661	Enteropathic arthropathies, right knee
M07.662	Enteropathic arthropathies, left knee

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Not Covered ICD-10 Codes (continued)ICD-10Not Covered

M08.011	Unspecified juvenile rheumatoid arthritis, right shoulder
M08.012	Unspecified juvenile rheumatoid arthritis, left shoulder
M08.019	Unspecified juvenile rheumatoid arthritis, unspecified shoulder
M08.211	Juvenile rheumatoid arthritis with systemic onset, right shoulder
M12.511	Traumatic arthropathy, right shoulder
M12.512	Traumatic arthropathy, left shoulder
M12.519	Traumatic arthropathy, unspecified shoulder
M12.551	Traumatic arthropathy, right hip

Not Covered ICD-10 Codes (continued)ICD-10Not Covered

M13.111	Monoarthritis, not elsewhere classified, right shoulder
M13.162	Monoarthritis, not elsewhere classified, left knee
M14.611	Charcot's joint, right shoulder
M14.651	Charcot's joint, right hip
M14.661	Charcot's joint, right knee
M14.811	Arthropathies in other specified diseases classified elsewhere, right shoulder
M16.0	Bilateral primary osteoarthritis of hip

Not Covered ICD-10 Codes (continued)ICD-10Not Covered

M16.11	Unilateral primary osteoarthritis, right hip
M17.0	Bilateral primary osteoarthritis of knee
M19.011	Primary osteoarthritis, right shoulder
M23.321	Other meniscus derangements, posterior horn of medial meniscus, right knee
M23.90	Unspecified internal derangement of unspecified knee

Not Covered ICD-10 Codes (continued)ICD-10Not Covered

M24.011	Loose body in right shoulder
M24.111	Other articular cartilage disorders, right shoulder
M25.511	Pain in right shoulder
M25.561	Pain in right knee
M43.07	Spondylolysis, lumbosacral region

Not Covered ICD-10 Codes (spine-related)ICD-10Not Covered

M48.07	Spinal stenosis, lumbosacral region
M50.20	Other cervical disc displacement, unspecified cervical region
M51.17	Intervertebral disc disorders with radiculopathy, lumbosacral region
M51.370	Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only
M54.51	Vertebrogenic low back pain

Not Covered ICD-10 Codes (soft tissue and bursopathies)ICD-10Not Covered

M67.811	Other specified disorders of synovium, right shoulder
M70.61	Trochanteric bursitis, right hip
M71.21	Synovial cyst of popliteal space [Baker], right knee
M75.01	Adhesive capsulitis of right shoulder
M75.101	Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic

Not Covered ICD-10 (group A)ICD-10Not Covered

M71.21	Synovial cyst of popliteal space [Baker], right knee
M71.22	Synovial cyst of popliteal space [Baker], left knee
M71.311	Other bursal cyst, right shoulder
M71.312	Other bursal cyst, left shoulder
M71.319	Other bursal cyst, unspecified shoulder
M71.351	Other bursal cyst, right hip
M71.352	Other bursal cyst, left hip
M71.359	Other bursal cyst, unspecified hip
M71.371	Other bursal cyst, right ankle and foot
M71.372	Other bursal cyst, left ankle and foot

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Not Covered ICD-10 (group B)ICD-10Not Covered

M71.852	Other specified bursopathies, left hip
M71.859	Other specified bursopathies, unspecified hip
M71.861	Other specified bursopathies, right knee
M71.862	Other specified bursopathies, left knee
M71.869	Other specified bursopathies, unspecified knee
M71.871	Other specified bursopathies, right ankle and foot
M71.872	Other specified bursopathies, left ankle and foot
M71.879	Other specified bursopathies, unspecified ankle and foot
M72.2	Plantar fascial fibromatosis
M75.00	Adhesive capsulitis of unspecified shoulder

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Not Covered ICD-10 (group C)ICD-10Not Covered

M75.121	Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic
M75.122	Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic
M75.20	Bicipital tendinitis, unspecified shoulder
M75.21	Bicipital tendinitis, right shoulder
M75.22	Bicipital tendinitis, left shoulder
M75.30	Calcific tendinitis of unspecified shoulder
M75.31	Calcific tendinitis of right shoulder
M75.32	Calcific tendinitis of left shoulder
M75.40	Impingement syndrome of unspecified shoulder
M75.41	Impingement syndrome of right shoulder

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Code currency — AMA/CMS updates

Policy update frequencyAMA and CMS code updates may occur more frequently than policy updates; policy may not reflect the latest code set.

Deleted/ineffective codesDeleted codes and codes not effective at time of service may not be eligible for reimbursement.

Responsibility to verify codesProviders should verify current code currency prior to claim submission due to potential timing differences between coding and policy updates.

Provider Requirements, Prior Authorization, and Documentation

Billing Rule

Benefit document and billing alignment

Reimbursement and coverage determinations are governed by the member's benefit plan document. Services will be reimbursed only when submitted with diagnosis and procedure codes that are covered under the applicable benefit plan and when submitted per the Coverage Policy criteria. Claims submitted without covered code(s) under the Coverage Policy will be denied as not covered. Providers should confirm billing codes and benefit terms prior to submission.

Submit supported covered diagnosis and procedure codes only
Confirm applicable member benefit plan document may supersede Coverage Policy

Prior Authorization

Genicular nerve RFA prior authorization

Prior authorization may be required for genicular nerve radiofrequency ablation (RFA) and other neuroablative procedures for knee osteoarthritis. When prior authorization is requested for genicular nerve RFA, documentation must include: a diagnosis of knee osteoarthritis; clear evidence of failure of conservative therapy (see conservative therapy requirements); description of prior treatments, durations, and outcomes; and relevant imaging or procedural notes when applicable. Cooled RF and other RF modalities may require prior authorization where conservative therapies have failed.

Prior Conservative Care Requirements

Failure of alternative treatments required

Failure of alternative treatments required: For trigeminal neuralgia, peripheral nerve destruction (e.g., percutaneous RF or glycerol rhizotomy) is considered only when the condition is refractory to medication and/or invasive alternatives such as microdecompression.Refractory to medication and/or invasive alternatives

Document prior therapies and lack of adequate response before proceeding to neurolytic procedures.

Document failure of first- and second-line therapies before considering ablation — 6–12 months prior to surgical/ablative intervention

Document first- and second-line therapy failure: For conditions such as plantar fasciitis and peripheral neuromas, document failure of first-line conservative measures (stretching, ice, activity modification, adaptive footwear, orthoses, NSAIDs, shock-absorbing inserts) and, when applicable, second-line measures (e.g., night splints, steroid injections) for an appropriate duration (e.g., 6–12 months for plantar fasciitis) prior to considering surgical or ablative interventions.

Frequency and Limit Notes

Genicular nerve RFA — frequency and prior auth notes (policy)

Genicular nerve RFA frequency/limitNo explicit numeric frequency limits specified in this section; prior authorization should document failed conservative therapy and appropriate diagnosis of knee osteoarthritis.

Prior authorization triggerPrior authorization is recommended for genicular nerve RFA and should include documentation of conservative therapy failure.

Evidence noteSome RCTs and meta-analyses report short-term benefit for genicular nerve RFA but studies are limited and heterogeneous.

Cooled RF / genicular nerve RF — frequency/limit notes

Cooled RF / genicular RF frequency limitsPolicy does not specify numeric frequency limits for cooled RF or genicular nerve RF in the Frequency Limits section.

Imaging and Procedural Guidance

Documentation Required

Document imaging guidance for RFA

Imaging guidance is generally used for radiofrequency ablation procedures; document imaging modality and guidance used (fluoroscopy, ultrasound, MRI, CT) in the procedure record.

RF procedures are frequently performed under imaging guidance.
Document the imaging modality used (e.g., fluoroscopy, US, MRI, CT) in operative notes.

Documentation Required

Document US or MRI guidance for Morton's neuroma ablation

For Morton's neuroma ablation, imaging guidance (ultrasound or MRI) is typically used in reported series; include imaging modality in procedure documentation.

Studies report US- or MRI-guided cryoablation/cryoneurolysis for Morton's neuroma.

Background, Definitions, and Scope

Background: peripheral nerve destruction techniques (chemical, thermal/radiofrequency, cryoablation, laser, electrical) are intended to interrupt pain transmission by creating lesions in nerve tissue. The policy notes variability in mechanism and durability among modalities and summarizes that overall evidence is limited, with few high-quality RCTs for many indications; trigeminal neuralgia is an exception where neurolytic lesioning may be appropriate in refractory cases.

Radiofrequency ablation (RFA) — definition and parameters

Definition of RFARadiofrequency ablation (RFA) uses probes/needles to transmit energy and produce thermal lesions; continuous RF typically 60–90°C for 90–120 seconds.

Variants and intentIncludes conventional (thermal), pulsed (lower temps ~42°C, not thought to destroy nerve), and cooled RF (creates larger lesions via cooled probe).

Imaging guidanceRFA is more frequently performed under imaging guidance per policy background and definitions.

Cryoablation — definition/clinical context

References and Revision History

References and citation notes: the policy cites society guidelines and multiple systematic reviews and randomized trials to support coverage determinations (see the References section and the Revision Details). The focused review dated 12/3/2023 that added a statement on percutaneous cryoablation of the lower extremities is recorded in the revision history.

2023-12-03focused_review

Focused review added a policy statement for percutaneous cryoablation of the lower extremities.

Explicitly Not Covered Procedures and Conditions

High-level Not Covered list (policy summary): sacroiliac joint ablation; knee ablation; hip ablation; shoulder ablation; foot/heel ablation; headache/occipital neuralgia ablation; intercostal neuralgia ablation; and ablation for CRPS, peripheral nerve entrapment/compression, or peripheral neuropathy are identified as not covered for treatment of pain in this policy excerpt.

Policy Summary

PayerCigna

PolicyPeripheral nerve destruction/ablation coverage (radiofrequency, cryoablation, chemical, laser, electrical)

Policy CodePolicy 0525

Change TypeFocused review (policy statement added)

Effective DateN/A

Next Review DateN/A

Key ActionDocument prior conservative therapy failure (e.g., 6-12 months where specified) and include covered diagnosis/procedure codes when submitting for coverage or prior authorization.

SourceLink

On This Page

Evidence for ablative approaches (cry o, alcohol, RF) is primarily from retrospective case series and small trials with mixed outcomes and uncertain long-term durability.

For plantar fasciitis: 6-12 months of conservative care before surgical/ablative intervention

Conservative measures (stretching, orthoses, injections) expected prior to consideration; many ablative modalities considered investigational for neuromas.

RCTs report benefits at 4–24 weeks to 6 months with methodological limitations.

Headache/occipital neuralgia: Insufficient evidence to demonstrate consistent safety and efficacy of peripheral nerve ablation for cervicogenic headache/occipital neuralgia.N/A

Multiple trials and reviews did not show consistent benefit; considered unsupported for routine coverage.

Code invalid date — M51.37

Invalid code notedM51.37 is listed as 'Code invalid 01/01/2025'.

Implication for claimsCodes that become invalid after the listed date may not be accepted for reimbursement; verify active code at time of service.

Reference locationInvalidation is documented in the policy's Not Covered ICD-10 list (see policy coding section).

Documented knee OA diagnosis
Documentation of conservative therapy failure (type, dates, duration, outcome)
Specify RF modality (e.g., cooled RF) and prior authorization submission if required

Documentation Required

Conservative therapy and outcomes documentation

Providers must document prior conservative therapies and their outcomes when requesting prior authorization for RF/neuroablative procedures. Documentation should describe the specific therapies attempted (e.g., physical therapy, weight loss, activity modification, orthoses, NSAIDs, intra-articular corticosteroid or viscosupplementation injections), durations (for some conditions 6–12 months may be expected, e.g., plantar fasciitis), and objective or patient-reported outcomes demonstrating inadequate response.

List each prior therapy, start/end dates, and response
For plantar fasciitis, document 6–12 months of first- and second-line therapies when applicable
Include diagnostic studies or specialist notes if available

Step Therapy

Conservative-first requirement

Professional guidance and this policy emphasize a conservative-first approach. Other modalities (weight loss, physical therapy, activity modification, NSAIDs, orthoses, injections, splints) should be attempted and documented prior to consideration of ablative techniques. Trigeminal neuralgia is an exception where neurolytic procedures may be considered for refractory cases after medication and/or surgical options have failed.

Attempt and document non-ablative measures prior to ablation
Trigeminal neuralgia: consider neurolytic procedures only after refractory to medication and other invasive options

Step Therapy

Conservative-first step therapy

Stepwise conservative care is recommended as first-line management across many conditions covered by this policy. Providers should pursue less invasive, evidence-based treatments prior to injections or ablative procedures and document stepwise care in the medical record and prior authorization submission when required.

First-line: exercise, weight loss, orthoses, NSAIDs, activity modification
Second-line: splints, targeted injections, walking cast, or other non-surgical measures before ablation

Prior Authorization

Prior authorization note

Certain neurolytic CPT codes for trigeminal procedures are considered medically necessary when the policy's criteria are met; other peripheral neuroablative codes may be considered experimental or not covered. Prior authorization submissions should reference the applicable CPT/HCPCS codes and whether the service is considered covered per the policy.

Medically necessary (when criteria met): 61790, 61791, 64600, 64605, 64610
Experimental/Unproven examples: 0441T; device codes C9808, C9809

Denial Risk

Prior authorization — excluded diagnoses

Some CPT/HCPCS codes and listed ICD-10 diagnoses are designated Not Covered or Not Reimbursable when used to support RF/neuroablative procedures for pain. Presence of excluded diagnosis codes on a prior authorization or claim may support denial. Providers should avoid using excluded codes when requesting authorization for ablative procedures and should check coding against the policy.

Example Not Covered CPT: 64624, 64632, 64640
Example Not Covered ICD-10 series: multiple headache/migraine codes (G43.x) and numerous musculoskeletal/arthropathy and bursitis codes listed in policy
Claims or PA requests listing excluded ICD-10 codes may be denied

Denial Risk

Insufficient evidence risk

Services that lack sufficient high-quality evidence to demonstrate safety and efficacy may be denied as investigational or not covered. Neuroablative treatments for peripheral neuroma (e.g., Morton's neuroma) and percutaneous cryoablation of distal/peripheral lower extremity nerves are examples where evidence is insufficient and treatment is considered experimental or investigational.

Procedures for peripheral neuroma are considered investigational
Percutaneous lower extremity cryoablation (0441T) considered experimental/unproven

Billing Rule

Not covered code risk

Procedures billed with codes explicitly listed as Not Covered or Reimbursable in this policy will be denied. Ensure that claims and prior authorization requests use only codes supported by the Coverage Policy and the member's plan. Using a code listed as Not Covered (CPT or HCPCS) may trigger automatic denial.

Not Covered CPT examples: 64624, 64632, 64640
Not Covered HCPCS/device codes: see policy (C9808, C9809 marked experimental for some indications)

Denial Risk

Denial risk when using listed diagnoses

Use of listed excluded diagnoses to justify RF or neuroablative procedures will likely render the service Not Covered. Prior authorization requests that list excluded ICD-10 primary diagnoses may be denied; corroborating documentation that the indication is appropriate and not excluded is necessary for favorable review.

If the primary diagnosis is in the policy's excluded ICD-10 lists, service is likely Not Covered
When submitting PA, list only covered/appropriate primary diagnosis codes and include supporting clinical rationale

Note

Medicare/LCD cross-check

Coverage determinations should be cross-checked with current Medicare National and Local Coverage Determinations (NCDs/LCDs) as contractor-specific policies may affect coverage or billing expectations. Providers should review applicable Medicare LCDs for procedures such as sacroiliac joint injections/procedures and Morton’s neuroma to align documentation and prior authorization submissions.

Review current NCD/LCDs (e.g., L39455, L34076, L34218) prior to submission
Medicare policies may provide contractor-specific requirements to consider

Documentation Required

Documentation impact

Prior authorization requests should include the primary diagnosis code(s) being treated and avoid listing diagnoses that the policy designates as Not Covered. If the medical record or PA submission includes an enumerated excluded diagnosis as the primary diagnosis, the service may be determined Not Covered or Not Reimbursable.

List covered primary diagnosis codes only
Include clinical rationale explaining why the requested procedure is indicated and not excluded by policy

Documentation Required

Documentation note

When submitting prior authorization requests or claims for RF/neuroablative procedures, include the specified excluded ICD-10 diagnosis codes if present in the chart per PA instructions, recognizing that listing these codes may support a denial. PA requests should explicitly state prior conservative treatments, durations, and outcomes to allow appropriate review.

Include all prior conservative therapy details and outcomes
Include diagnostic imaging or prior procedure notes when relevant

Note

No policy statement changes noted in the

Policy revision history: annual reviews on 2024-02-15 and 2025-02-15 noted no policy statement changes. A focused review on 2023-12-03 added a policy statement for percutaneous cryoablation of the lower extremities. Providers should reference the revision history when evaluating which statements apply to the date of service.

Annual review dates: 2024-02-15, 2025-02-15 — No policy statement changes
Focused review 2023-12-03 — Added percutaneous cryoablation lower extremity statement

6-12 months (plantar fasciitis) or documentation of failed conservative care

Documentation should include duration and outcomes of prior conservative therapies.

Conservative therapy and response should be documented prior to ablation consideration

Conservative therapy and response documented prior to ablation: For peripheral neuromas (e.g., Morton's neuroma) and similar foot conditions, document trials of adaptive footwear, orthotics, and injections (anesthetic/corticosteroid, alcohol/phenol where used) and their outcomes before considering ablative procedures.Documented trial and inadequate response to conservative therapy

Surgical excision remains an option when conservative care fails; ablative approaches have limited and mixed evidence.

Attempt other treatment modalities prior to ablative therapy per professional guidance and study inclusion criteria

Attempt other treatment modalities prior to ablative therapy: Initial therapy should include weight loss, physical therapy, NSAIDs, and consideration of intra-articular injections and other nonoperative measures; these should be attempted before ablative procedures per professional guidance and typical study inclusion criteria.N/A

Professional society guidance and study protocols commonly require failure of conservative modalities prior to enrollment or treatment.

Attempt conservative therapies prior to ablation — professional guidance reminder

Professional guidance — conservative first: Professional society guidance (ASA Task Force, ASIPP, ACFAS) recommends attempting other treatment modalities before considering ablative techniques; chemical denervation should not be used routinely for chronic noncancer pain.N/A

Cryoablation may be used in selected patients per guidance, but most ablative techniques require prior conservative therapy.

(placeholder) conservative treatment requirement block

Conservative treatment requirement (placeholder): Prior conservative therapies (type, duration, and outcomes) should be documented in the medical record prior to authorization or performance of ablative procedures; documentation may include pain scores and functional measures used in clinical studies.Documented failure of conservative care

This block captures the policy expectation for documentation though specific plan authorization rules may vary.

(placeholder) conservative treatment requirement block continued

Conservative treatment requirement continued (placeholder): For knee osteoarthritis considered for genicular RFA, prior conservative care (e.g., weight loss, PT, NSAIDs, intra-articular injections) and failure of these modalities are typically required before RFA is considered; prior authorization processes often request this documentation.Documented failure of conservative care

Clinical trials and meta-analyses generally enrolled patients after failure of conservative measures.

Prior authorization expectation

Prior authorization may be expected for cooled RF when conservative treatments have failed; document prior conservative care.

Imaging/technique noteTrials of cooled RF used fluoroscopic or other image-guidance; technique and parameters vary across studies.

Frequency limits — general placeholder notes

Frequency limits — unspecifiedNo specific numeric frequency limits provided in the policy fragment for many procedures; refer to clinical criteria and PA requirements.

Focused review noteA focused review (12/3/2023) added a policy statement for percutaneous cryoablation of the lower extremities; specifics not included here.

Provider actionProviders should include documentation of prior conservative care and check prior authorization requirements for repeated procedures.

Percutaneous cryoablation — focused review (policy addition)

Percutaneous cryoablation policy changeFocused review on 12/3/2023 added a policy statement for percutaneous cryoablation of the lower extremities.

Status in excerptSpecific coverage details and frequency limits for percutaneous cryoablation are not included in the provided document fragments.

Technique definition referenceCryoablation uses a cryoprobe and freezing agent to form a lesion in nerve tissue (see definitions/technique sections).

Documentation Required

Document fluoroscopic guidance for genicular RFA when used

Studies of genicular nerve radiofrequency ablation report fluoroscopic guidance in many trials; when performing or authorizing genicular RFA, document the imaging guidance used.

Some RCTs and case series used fluoroscopic guidance for genicular RFA.

Billing Rule

Reflect imaging guidance in coding for certain CPTs (e.g., 64610, 64624)

Some CPT descriptions referenced in the policy (for example, 64610 and 64624) indicate performance under radiologic monitoring or imaging guidance; ensure claims and operative reports reflect imaging guidance when applicable.

Check CPT descriptors for imaging guidance language (e.g., 64610, 64624).

Documentation Required

Document imaging guidance used; literature often implies CT/fluoro guidance

Technique reports cited in the literature imply imaging guidance (for example, CT-guided percutaneous radiofrequency thermocoagulation) for some procedures, but the policy does not state an explicit coverage imaging requirement; document guidance used in the record.

Definition of cryoablation/cryodenervationCryoablation employs a cryoprobe and a freezing agent to form a lesion in nerve tissue, interrupting pain transmission.

Uses reportedTechnique has been reported for plantar fasciitis and Morton's neuroma in small case series and limited studies.

Safety considerationsCryoablation may be associated with procedural complications; evidence base is limited and cautious use is advised.

Chemical ablation — definition and evidence notes

Definition of chemical neurolysisChemical ablation uses agents such as alcohol, phenol, or glycerol applied to nerve tissue to destroy nerve fibers and inhibit function.

Clinical use and evidenceAlcohol/phenol injections have been used for Morton's neuroma with mixed and limited long-term results; professional groups caution against routine use.

GuidanceASA Task Force advises chemical denervation should not be used routinely for chronic noncancer pain.

Radiofrequency ablation (RFA) — percutaneous neuroablative technique

RFA as percutaneous neuroablative techniquePercutaneous RFA creates thermal lesions to denervate pain-generating nerves; modalities include conventional, cooled, and pulsed RF.

Technique considerationsProbe placement and parameters (temperature, duration) affect lesion size; cooled RF may create larger lesions via tip cooling.

Clinical applicationUsed across targets including medial branches, genicular nerves, and peripheral joints with variable evidence quality.

Cryoablation — technique and reported uses

Cryoablation technique summaryCryoablation uses freezing via a cryoprobe to ablate nerve tissue; reported for plantar fasciitis and Morton's neuroma in small series.

Evidence levelClinical evidence is limited to small retrospective or case series with short follow-up; randomized data are sparse.

Imaging guidanceSome reports describe MRI- or ultrasound-guided cryoablation techniques for peripheral neuromas.

Chemical ablation (alcohol) — Morton's neuroma evidence

Alcohol injection for Morton's neuromaAlcohol injection (chemical ablation) has limited and mixed long-term results for Morton's neuroma; many studies are small case series.

Outcomes variabilityLong-term follow-up studies report incomplete durability with some patients requiring later surgical excision.

Evidence gapOverall evidence is insufficient and lacks well-designed controlled trials comparing with established alternatives.

Genicular nerve radiofrequency ablation — definition and variants

Genicular nerve RFA definitionGenicular nerve RFA targets sensory branches supplying the knee to reduce osteoarthritic knee pain; includes conventional, cooled, and pulsed variants.

Clinical evidenceMultiple RCTs and meta-analyses report short-term pain and function improvements, but trials are limited by small size and heterogeneity.

Prior conservative therapyStudies and policy note procedures are generally considered after failure of conservative treatments; prior authorization may require documentation.

Occipital neuralgia / cervicogenic headache — targeted procedures

Occipital neuralgia/cervicogenic headache interventionsProcedures target occipital and upper cervical nerves (e.g., pulsed RF, RF neurotomy, nerve blocks) to treat headache syndromes.

Evidence summaryThere is insufficient evidence to demonstrate safety and efficacy of peripheral nerve ablation for cervicogenic headache or occipital neuralgia.

Non-surgical optionsGuidelines list non-surgical interventions (PT, meds, nerve blocks) and reserve surgical options for refractory cases.

Chemical denervation — definition and recommendation against routine use

Definition of chemical denervationChemical denervation applies agents such as alcohol or phenol to chemically destroy nerve tissue to interrupt pain transmission.

RecommendationASA Task Force recommends chemical denervation should not be used routinely for chronic noncancer pain.

Clinical cautionChemical methods may produce neuroma formation and have unpredictable long-term outcomes; use is discouraged except in select cases.

Not Covered / Not Reimbursable — definition label

Not Covered / Not Reimbursable labelServices designated 'Not Covered or Reimbursable' are excluded from payment when used to treat listed pain conditions.

ApplicationThe label applies to specific CPT and ICD-10 codes when billed for the disallowed indications described in the policy.

Provider implicationClaims with these codes for excluded pain diagnoses are subject to denial as not covered or not reimbursable.

Not Covered / Not Reimbursable — diagnoses listed

Diagnoses listed as Not CoveredNumerous ICD-10 codes across chunks 59–73 and 72–91 are explicitly designated Not Covered when used to treat pain conditions (examples include M71.21, M71.561, M16.11, G43.xx series).

Procedure codes often excludedCertain CPT codes (e.g., 64624, 64632, 64640) are listed among Not Covered or Not Reimbursable when billed for pain treatment.

Impact on prior authPresence of these diagnoses on prior authorization or claim submissions supports denial of coverage per policy.

Neuroablative/interventional procedures — references cited

References supporting proceduresPolicy cites a broad set of references (e.g., ASPN guidelines, RCTs and systematic reviews) supporting discussion of neuroablative/interventional procedures.

Scope of evidenceReferences include randomized trials, meta-analyses, systematic reviews, and society guidelines addressing RFA, cooled RF, cryoablation, and chemical neurolysis.

Use for policy rationaleThese references inform the policy's coverage determinations and clinical guidance across multiple anatomical targets.