ModifiedCignaPolicy 0525

Peripheral Nerve Destruction for Pain Conditions

Defines Cigna's coverage stance for percutaneous cryoablation and other peripheral nerve ablation techniques for treatment of pain conditions across commercial health benefit plans; affects providers seeking reimbursement under Cigna-administered plans.

Policy Summary

PayerCigna

PolicyPeripheral Nerve Destruction for Pain Conditions

Policy CodePolicy 0525

Change TypeAnnual review — material edits

Effective Date5/15/2026

Next Review Date2/15/2027

Key ActionPrior authorization should document prior conservative therapy and a positive diagnostic blockade response (e.g., ≥50% pain relief for SIJ) when considering neuroablative procedures.

SourceLink

POLICY UPDATE CHANGES

Removed policy statement for peripheral nerve destruction for trigeminal neuralgia.

Revised policy statement for percutaneous cryoablation.

Added policy statement for pulsed radiofrequency ablation.

Revised list of not covered or reimbursable conditions (no policy statement changes).

0525Policy Number

5/15/2026Effective

2/15/2027Next review

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Not medically necessary

up to 6 monthsDurability (some studies)

multipleRegions covered in codes

Coverage Criteria — Peripheral Nerve Destruction

Diagnosis code list (informational only)

The following ICD-10-CM diagnosis codes are provided for informational context only and are referenced in the policy to illustrate conditions discussed. Inclusion of a code does not imply coverage or reimbursement; coverage determinations are based on the clinical criteria elsewhere in this policy.

{

"text":"G43.001 — Migraine without aura, not intractable, with status migrainosus"

}

{

"text":"G43.009 — Migraine without aura, not intractable, without status migrainosus"

}

{

"text":"G43.011 — Migraine without aura, intractable, with status migrainosus"

}

{

"text":"G43.019 — Migraine without aura, intractable, without status migrainosus"

}

{

"text":"G43.101 — Migraine with aura, not intractable, with status migrainosus"

}

{

"text":"G43.109 — Migraine with aura, not intractable, without status migrainosus"

}

{

"text":"G43.111 — Migraine with aura, intractable, with status migrainosus"

}

{

"text":"G43.119 — Migraine with aura, intractable, without status migrainosus"

}

{

"text":"G43.401 — Hemiplegic migraine, not intractable, with status migrainosus"

}

{

"text":"G43.409 — Hemiplegic migraine, not intractable, without status migrainosus"

}

{

"text":"G43.411 — Hemiplegic migraine, intractable, with status migrainosus"

}

{

"text":"G43.419 — Hemiplegic migraine, intractable, without status migrainosus"

}

{

"text":"M05.751 — Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement"

}

{

"text":"M05.752 — Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement"

}

{

"text":"M05.759 — Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement"

}

{

"text":"M05.761 — Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement"

}

{

"text":"M05.762 — Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement"

}

{

"text":"M05.769 — Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement"

}

{

"text":"M05.771 — Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement"

}

{

"text":"M05.772 — Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement"

}

{

"text":"M05.779 — Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement"

}

{

"text":"M05.811 — Other rheumatoid arthritis with rheumatoid factor of right shoulder"

}

Coding — CPT/HCPCS/ICD-10 and Device Codes

Considered Not Medically Necessary — Percutaneous Cryoablation / Device HCPCSmixedNot Covered

64999	Unlisted procedure, nervous system
0440T	Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441T	Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
0442T	Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
C9808	Nerve cryoablation probe, including probe and disposable system components
C9809	Cryoablation needle, including needle/tip and disposable system components

Not Covered or Reimbursable — Neurolytic Agent Destruction CPT CodesCPTNot Covered

64620	Destruction by neurolytic agent, intercostal nerve
64624	Destruction by neurolytic agent, genicular nerve branches; includes 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 or Reimbursable — Headache / Migraine / Neuralgia / Plexus / Mononeuropathy DiagnosesICD-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
G43.401	Hemiplegic migraine, not intractable, with status migrainosus
G43.409	Hemiplegic migraine, not intractable, without status migrainosus

1–10 of 82

1/9

Actionable Provider Requirements and Prior Authorization

Denial Risk

Not medically necessary — ablative peripheral nerve procedure codes

The following CPT/HCPCS and unlisted procedure codes for ablative peripheral nerve procedures are considered not medically necessary and will not be reimbursed when submitted for the listed pain indications: 0440T, 0441T, 0442T, C9808, C9809, 64999, and destruction-by-neurolytic-agent CPTs (e.g., 64620, 64624, 64632, 64640).

0440T, 0441T, 0442T (percutaneous cryoablation procedure codes) [[chunk 7]]
C9808, C9809 (cryoablation device HCPCS) [[chunk 7]]
64999 (unlisted procedure, nervous system) [[chunk 7]]
64620, 64624, 64632, 64640 (destruction by neurolytic agent CPTs) [[chunk 8]]

Note

Prior authorization not specified in this excerpt

This excerpt does not specify a formal prior authorization program or requirements; the document instead lists diagnosis and procedure codes and notes that reimbursement is contingent on submission of covered diagnosis/procedure codes per the plan.

Conservative Treatment and Diagnostic Confirmation Requirements

Frequency and Repeat Procedure Guidance

Procedural frequency limits (note)

Procedural frequency limitsNo procedural frequency limits are included in the provided document chunks.

Reference guidanceRefer to main policy sections or Medicare LCD/NCDs for any specific frequency restrictions not present here.

ImplicationAbsence of limits in this excerpt does not imply there are none elsewhere in the full policy or payer guidance.

Repeat procedures — evidence statement

Repeat procedures evidence stanceEvidence is insufficient to guide timing or indications for repeat RF or PRF procedures; specialty guidance notes lack of long-term outcomes to direct repeat procedures.

Clinical discretionRepeat intervention decisions should consider individual response and available evidence; documentation of prior response recommended.

Imaging and Procedural Guidance

Billing Rule

Percutaneous cryoablation codes (0440T–0442T) imply imaging guidance — document accordingly

Percutaneous cryoablation CPT/T codes (0440T–0442T) reference imaging guidance in their code descriptions; include appropriate imaging guidance documentation when submitting claims.

0440T–0442T descriptions include imaging guidance in the CPT/HCPCS listing [[chunk 7]]
Technical reports and studies referenced describe use of fluoroscopy and ultrasound guidance for cryo/CRFA procedures [[chunk 122]]

Note

No explicit imaging requirements in this excerpt — use imaging when indicated

This excerpt does not specify imaging requirements for diagnosis beyond listing spinal condition codes; use imaging only when clinically indicated to support diagnosis.

Spinal condition ICD-10 lists are provided but no explicit imaging requirements are stated in these chunks [[chunk 31]]

Procedures Not Covered or Considered Investigational

Percutaneous cryoablation; pulsed radiofrequency ablation; and peripheral nerve destruction using cryoablation, laser, electrical, chemical or radiofrequency methods are identified in the policy as procedures that are not covered or reimbursable when used to treat the pain conditions specified in the coverage statement (see code listings and device HCPCS in the policy).

Alternative entries in the policy reiterate that neurolytic agent destruction codes (for example CPT 64620, 64624, 64632, 64640) and unlisted nervous system procedure code 64999 are considered not medically necessary for the specified pain indications and therefore are not covered.

The policy also lists cryoablation procedure codes (0440T–0442T) and associated cryoablation device HCPCS (C9808, C9809) among services considered not medically necessary for the pain conditions outlined and subject to noncoverage.

This excerpt does not reproduce the complete Medicare determinations; the policy directs readers to consult applicable Medicare NCDs and LCDs (for example NCD 160.1 and several contractor LCDs) for explicit noncoverage decisions and the most current Medicare coverage language.

Additional not-covered entries in the policy reaffirm that peripheral nerve destruction modalities (cryoablation, pulsed RF, neurolytic injections, and related techniques) are not reimbursable for the enumerated pain conditions and that claims billed with the listed procedure codes will be considered not covered when used for those indications.

Definitions and Terminology

Definition — Peripheral nerve destruction (ablation) and techniques

Definition — Peripheral nerve destruction (ablation)Ablation refers to techniques used to destroy or disable peripheral or truncal nerves to reduce pain transmission, including cryoanalgesia, thermal RFA (conventional/cooled), pulsed RFA, and chemical neurolysis.

Techniques listCommon modalities: cryoneuroablation/cryoanalgesia, conventional thermal radiofrequency ablation (RFA), cooled RFA (CRFA), pulsed radiofrequency (PRF), and chemical neurolysis (phenol/alcohol).

Clinical purposeUsed to interrupt nociceptive signaling from targeted sensory nerve branches when diagnostic/therapeutic blocks indicate the nerve supplies the pain.

Cryoanalgesia (cryoablation) definition

Cryoanalgesia (cryoablation) definitionA technique using cold (approximately -70°C) to freeze nerve tissue, creating temporary axonal injury that blocks pain while preserving surrounding nerve structure for potential regeneration.

Background and Evidence Summary

Percutaneous cryoablation and other neuroablative techniques (electrical, laser, chemical neurolysis, conventional/cooled/pulsed radiofrequency) are procedures intended to interrupt peripheral nerve signaling to relieve pain. Cryoanalgesia uses extreme cold (producing reversible axonal injury while preserving connective tissue), thermal RFA applies heat (conventional thermal RFA typically ~60–90°C for lesioning), and pulsed RFA delivers intermittent bursts generally maintaining temperatures below 38–42°C. The policy frames these techniques within the context of the evidence base: some indications have limited randomized data or small trials, while many peripheral applications lack sufficient high-quality evidence to establish safety and effectiveness, which underlies the not-covered determinations for numerous pain conditions.

Revision History

2026-02-15annual_reviewLatest

Removed policy statement for peripheral nerve destruction for trigeminal neuralgia; revised policy statement for percutaneous cryoablation; added policy statement for pulsed radiofrequency ablation.

Policy Summary

PayerCigna

PolicyPeripheral Nerve Destruction for Pain Conditions

Policy CodePolicy 0525

Change TypeAnnual review — material edits

Effective Date5/15/2026

Next Review Date2/15/2027

Key ActionPrior authorization should document prior conservative therapy and a positive diagnostic blockade response (e.g., ≥50% pain relief for SIJ) when considering neuroablative procedures.

SourceLink

On This Page

No prior authorization criteria are detailed in the provided sections — use submitted codes and plan terms to determine coverage [[chunk 18]]
Claims must be submitted with appropriate covered codes; services billed for conditions not covered by the policy will be denied [[chunk 3]]

Prior Authorization

Perform diagnostic occipital nerve block before RFN

Per specialty society guidance, a diagnostic occipital nerve block should be performed and alternative etiologies excluded prior to occipital radiofrequency neurotomy (RFN).

ASPN notes a diagnostic occipital nerve block is required before RFN and that PRF evidence is strongest among RFN techniques [[chunk 52]]
Professional guidance describes occipital nerve blocks (greater/lesser occipital or C2/C3) for diagnosis and selection prior to interventions [[chunk 51]]
Diagnosis relies on clinical evaluation and relief after diagnostic block supports the diagnosis of cervicogenic headache/occipital neuralgia [[chunk 44]]

Documentation Required

Confirm diagnostic injection response and prior conservative therapy

Prior authorization and clinical review should confirm both a documented response to an appropriate diagnostic injection (e.g., ≥50% relief for SIJ) and that adequate conservative therapy has been tried and failed.

SIJ trial eligibility in trials required ≥50% pain relief from diagnostic/therapeutic SIJ injection and provocation testing [[chunk 66]]
Society guidance and the policy require failure of conservative measures prior to considering neuroablation [[chunk 65]]
Conservative nonpharmacologic and pharmacologic therapies are recommended prior to nerve ablation for headache/occipital neuralgia [[chunk 45]]

Prior Authorization

Prior auth: document conservative therapy and diagnostic block for RFA requests

When requesting prior authorization for radiofrequency ablation, include documentation of prior conservative therapy trials and a positive diagnostic blockade response consistent with society guidance.

ASPN recommends considering neuroablation for SIJ only after an adequate conservative trial and a positive diagnostic blockade [[chunk 72]]
ASIPP and ASRA-PM guidance emphasize diagnostic block confirmation (e.g., medial branch block criteria) and conservative therapy before RFA [[chunk 71]]
The policy indicates prior authorization should document prior conservative therapy and positive diagnostic blockade when considering RFA for SIJ, facet, or hip pain [[chunk 49]]

Prior Authorization

Prior auth: confirm conservative therapy and diagnostic response for plantar fasciitis

For plantar fasciitis–related ablative interventions, prior authorization should confirm failure of first- and second-line conservative therapies (typically 6–12 months) and document diagnostic block results when used.

Plantar fasciitis conservative pathway: first-line measures then second-line (night splints, steroid injections); surgical/ablative methods considered after 6–12 months of failed care [[chunk 95]]
RCTs of PRFA in plantar fasciitis required prior conservative therapy (e.g., ≥6 months) as an inclusion criterion [[chunk 97]]
The policy states prior authorization should confirm 6–12 months of prior conservative management for plantar fasciitis and document diagnostic block response when used for genicular RFA [[chunk 50]]

Note

Check applicable Medicare NCDs/LCDs for local coverage requirements

Review applicable Medicare NCDs and LCDs (e.g., NCD 160.1; NGS L39455; Noridian L34076, L34218) to ensure local Medicare coverage requirements and documentation are met prior to submission.

Policy cites NCD 160.1 and relevant LCDs for sacroiliac procedures, Morton’s neuroma, and nerve blockade — review current Medicare policy for up-to-date requirements [[chunk 108]]

Note

Policy updates that may affect prior authorization

Policy changes from the annual review may affect prior authorization criteria — pulsed radiofrequency was added, percutaneous cryoablation language was revised, and the peripheral nerve destruction statement for trigeminal neuralgia was removed.

Annual review summary: added pulsed RF statement; revised cryoablation statement; removed trigeminal neuralgia peripheral nerve destruction policy language (effective 2/15/2026) [[chunk 137]]

Step Therapy

Require trial of conservative therapies before ablation

Document that an adequate trial of conservative therapies (nonpharmacologic and pharmacologic) was attempted and found insufficient before considering nerve ablation.

Conservative measures include physical therapy, massage, posture exercises, TENS, antidepressants, antiepileptics, muscle relaxants, and NSAIDs [[chunk 45]]
ASA/ASRA guidance recommends reserving neuroablative procedures for individuals who have not achieved adequate relief with conservative or less invasive therapies [[chunk 58]]
Professional guidelines emphasize conservative therapy failure before ablative procedures are considered [[chunk 70]]

Step Therapy

Step therapy: ablation only after conservative/less invasive treatment failure

Neuroablative procedures should be reserved for patients who have failed conservative and less invasive treatments; proceed to ablation only after documented inadequate response.

ASA/ASRA recommend reserving ablative procedures for those who have not achieved adequate relief with conservative or less invasive therapies [[chunk 58]]
Guidelines consistently state neuroablative procedures are considered only after failure of conservative treatments [[chunk 70]]

Step Therapy

Document ≥3-month conservative therapy trial for selected indications

For some indications (e.g., SIJ, facet-mediated pain), document a trial of at least three months of conservative therapies prior to considering neuroablation, consistent with guideline recommendations.

ASRA-PM recommends a three-month trial of conservative therapies prior to facet interventions [[chunk 73]]
Trials of SIJ therapies and guideline-recommended pathways require chronicity (≥3 months) before neuroablative procedures [[chunk 71]]

Step Therapy

Follow stepwise conservative → injection → ablation pathway

Follow a stepwise care pathway: initial conservative management (orthotics, activity modification, NSAIDs), progress to second-line therapies (steroid injections, night splints) and consider ablative interventions only after these measures fail.

Plantar fasciitis pathway: first-line (stretching, ice, activity modification, orthoses, NSAIDs) then second-line (night splints, steroid injections) before surgical/ablative options [[chunk 95]]
ASA/ASRA guidance supports reserving ablative techniques until conservative/less invasive options have failed [[chunk 58]]
Policy describes stepwise progression from conservative care to injections then ablation in multiple indications [[chunk 98]]

Billing Rule

Use appropriate, current codes and submit only covered services

When billing, use the most appropriate procedure and diagnosis codes current on the effective date; reimbursement is only provided if the requested service is a covered benefit and submitted with the appropriate codes.

Claims submitted for services without covered code(s) under the applicable Coverage Policy will be denied as not covered [[chunk 3]]
Providers must use the most appropriate codes as of the effective date when billing [[chunk 3]]

Documentation Required

Document diagnostic evaluation and imaging when indicated

Support the diagnosis with clinical history, physical exam findings, and imaging when indicated; relief after a diagnostic nerve block should be documented to support the targeted pain generator.

Diagnosis of cervicogenic headache/occipital neuralgia relies on clinical criteria and imaging when indicated; relief following diagnostic block supports diagnosis [[chunk 44]]
Policy states diagnosis should be supported by history, exam, and imaging (MRI/CT) where indicated and that relief after diagnostic nerve block supports the diagnosis [[chunk 63]]
Society guidance requires exclusion of alternative etiologies and use of diagnostic blocks prior to RFN [[chunk 52]]

Documentation Required

Document chronicity, prior therapies, and injection responses

Include required clinical documentation in prior authorization or chart notes: symptom chronicity (e.g., ≥3 months for SIJ), prior conservative therapies and durations, and response to diagnostic or therapeutic injections (e.g., ≥50% relief when required).

Document chronicity such as ≥3 months for SIJ pain as used in trial eligibility [[chunk 66]]
Policy requires documentation of prior conservative therapies and duration and diagnostic injection response (e.g., ≥50% relief) [[chunk 64]]
Guidelines for medial branch RFA recommend documenting diagnostic block responses and prior conservative care [[chunk 71]]

Documentation Required

Document diagnostic block response (e.g., >50% pain reduction) when required

When diagnostic blocks are required by protocol or trial criteria, document the block method and a responder-level reduction in pain (for example, >50% pain reduction after PENG or genicular blockade) before proceeding to neurolytic intervention.

Reysner PENG neurolysis trial proceeded only for subjects with >50% pain reduction after diagnostic PENG block [[chunk 78]]
SIJ and genicular trial protocols and policy examples require ≥50% relief from diagnostic injections to identify responders [[chunk 65]]
Document >50% pain reduction after diagnostic genicular blockade when required by study/trial protocols [[chunk 95]]

Documentation Required

Document prior conservative therapies and duration

Prior authorization and medical records should list prior conservative therapies tried and their durations (e.g., stretching, orthotics, NSAIDs, steroid injections, night splints, walking cast) to demonstrate failure of conservative care.

For plantar fasciitis, document first- and second-line therapies tried and duration (typically 6–12 months) [[chunk 95]]
Policy requires documentation of prior conservative therapies (examples listed) and duration when seeking ablative interventions [[chunk 91]]
SIJ trial eligibility included documentation of conservative therapy failure prior to CRFA [[chunk 66]]

Note

Consult referenced Medicare NCD/LCD documents for required documentation

Refer to cited Medicare NCDs/LCDs (e.g., NCD 160.1; NGS L39455; Noridian L34076, L34218) for Medicare-specific documentation and coverage requirements when treating Medicare beneficiaries.

The policy lists multiple Medicare determinations and instructs providers to review current Medicare policy for up-to-date coverage and documentation requirements [[chunk 108]]

Denial Risk

Denial risk — unsupported or noncovered procedure/diagnosis combinations

Claims for services that are not covered under this policy (including the not medically necessary procedure codes listed) will be denied as not covered if submitted with unsupported diagnosis/procedure combinations.

Claims for services not accompanied by covered code(s) under the applicable Coverage Policy will be denied [[chunk 3]]
Policy explicitly lists ablative procedures considered not medically necessary and not covered for the specified pain conditions [[chunk 5]]
Specific not medically necessary procedure codes are identified in the policy [[chunk 7]]

Denial Risk

Evidence insufficiency — occipital neuralgia/cervicogenic headache (risk of noncoverage)

There is insufficient evidence to support peripheral nerve ablation for cervicogenic headache or occipital neuralgia; absence of supportive evidence may lead to noncoverage for these indications.

Policy states insufficient evidence exists to demonstrate safety and efficacy of peripheral nerve ablation for cervicogenic headache and/or occipital neuralgia [[chunk 53]]
Diagnosis and selection rely on clinical criteria and diagnostic block response but overall evidence is limited [[chunk 44]]

Denial Risk

Denial risk if conservative therapy and diagnostic confirmation are not documented

Failure to document adequate trials of conservative therapy and diagnostic block confirmation may result in denial of coverage for neuroablative procedures.

ASA/ASRA guidance recommends reserving neuroablative procedures for patients who have not achieved adequate relief with conservative therapies [[chunk 58]]
ASPN and ASIPP recommend positive diagnostic blockade and adequate conservative therapy prior to neuroablation for SIJ and related procedures [[chunk 72]]
Guidelines emphasize conservative therapy failure and diagnostic confirmation as prerequisites for ablative procedures [[chunk 70]]

Denial Risk

Insufficient evidence — peripheral neuromas (Morton's neuroma) — denial risk

Neuroablative treatments for peripheral neuromas (e.g., Morton's neuroma) are considered investigational/research due to insufficient evidence; coverage is unlikely and may be denied.

Policy states there is insufficient evidence to support neuroablative treatment for Morton's neuroma and such treatments should be considered research [[chunk 102]]
Literature notes ablative approaches (alcohol injections, RF) have limited evidence and are not established as standard treatment [[chunk 99]]

Denial Risk

Adhere to Medicare NCD/LCDs to avoid denials

Review current Medicare NCDs/LCDs before treating Medicare patients; failure to adhere to Medicare coverage determinations may trigger claim denials.

Policy explicitly directs providers to review applicable Medicare NCD/LCDs which may influence coverage determinations and denials [[chunk 108]]

RecommendationConsult full policy and specialty guidance when considering repeat neuroablative procedures.

Frequency limits — excerpt note

Explicit limits absentNo explicit frequency limits are stated in the provided document portion.

ActionCheck the full policy or Medicare LCD/NCDs for any procedure-specific frequency restrictions.

Documentation noteLack of stated limits in excerpt requires reliance on full policy text for utilization review decisions.

Frequency limits — genicular/section note

Section frequency limits absentNo explicit frequency limits are stated in this section of the extract (genicular CRFA noted separately in other chunks).

Genicular CRFA referenceRefer to genicular CRFA evidence and full policy sections for procedural timing guidance.

RecommendationUse documented clinical response and specialty guidance when evaluating repeat CRFA requests.

See Medicare LCD/NCDs for frequency limits

Medicare LCD/NCD guidanceSee referenced Medicare LCDs/NCDs (e.g., NCD 160.1; NGS L39455; Noridian L34076, L34218) for specific frequency limits; not detailed in this excerpt.

Action for reviewersReview current Medicare determinations for local coverage restrictions that may apply to billing and authorization.

NoteMedicare policy language may be updated separately from this commercial policy; always verify current LCD/NCD status.

Frequency limits — refer to main policy

No explicit frequency limits in extractNo explicit frequency limits are stated in this extract; refer to the main policy sections for detailed frequency guidance.

Operational noteUtilization management should consult full policy text for procedural intervals and repeat criteria.

Medicare cross-checkAlso consult applicable Medicare LCD/NCDs when making coverage determinations.

Policy indicates diagnosis relies on clinical criteria and imaging (MRI/CT) when indicated [[chunk 44]]

Documentation Required

Obtain diagnostic imaging when indicated before ablation

Obtain appropriate diagnostic imaging when clinically indicated prior to neuroablative procedures to exclude alternative etiologies and support the procedural indication.

Diagnosis of cervicogenic headache and related conditions relies on clinical criteria and imaging (MRI/CT) where indicated to exclude other causes [[chunk 44]]
Policy notes diagnostic evaluation including imaging should be used to confirm etiology prior to ablation when indicated [[chunk 110]]

Documentation Required

Shoulder neuroablation — document imaging to confirm etiology

For shoulder neuroablation, document imaging and clinical testing that confirm shoulder as the pain source (e.g., rotator cuff/arthritis) prior to ablative procedures.

RCTs of PRFA in shoulder pain required clinical tests (Neer/Hawkins) and imaging for inclusion [[chunk 62]]
Policy notes imaging may be used to confirm shoulder etiology (rotator cuff/arthritis) when selecting neuroablation [[chunk 61]]

Documentation Required

Use and document image guidance for diagnostic blocks and ablative procedures

Document use of image guidance (fluoroscopy or ultrasound) for diagnostic blocks and for RFA/cryo/neurolysis procedures, consistent with techniques described in cited studies and best-practice reports.

Several cited technical reports and studies describe using fluoroscopy and/or ultrasound guidance for diagnostic blocks and ablative procedures [[chunk 122]]
Policy notes image guidance (fluoroscopy or ultrasound) is commonly used for diagnostic block and neuroablation procedures [[chunk 112]]
Genicular and cooled RFA procedural studies referenced technical guidance using fluoroscopy/ultrasound [[chunk 114]]

Documentation Required

Document imaging modality (fluoroscopy or ultrasound) for genicular/foot procedures

For genicular nerve blocks, cooled RFA, and foot procedures, document the imaging modality used (fluoroscopy or ultrasound) consistent with the procedural technique.

Genicular CRFA trials and extension cohorts used fluoroscopic guidance for diagnostic blocks and procedures [[chunk 91]]
Policy notes fluoroscopy or ultrasound may be used for genicular and foot procedures per technique [[chunk 113]]
Technical reports describe combined fluoroscopy and ultrasound approaches for cooled RFA and genicular procedures [[chunk 122]]

Documentation Required

Document image guidance for RFA/cooled RF procedures

When performing radiofrequency ablation (including cooled RF), include documentation that image guidance (fluoroscopy and/or ultrasound) was used as commonly described in the literature.

Cooled RF and other RFA technical reports describe routine use of fluoroscopy and/or ultrasound guidance to target articular sensory branches [[chunk 122]]
Policy notes imaging guidance is commonly used for RFA/cooled RF procedures [[chunk 114]]

Clinical useApplied to peripheral nerves for pain relief; device examples and RCTs referenced in literature.

RisksMay cause skin color changes or frostbite-type injury; other complications include bleeding, infection, and prolonged sensory disturbances.

Radiofrequency ablation (RFA) — conventional thermal RFA

Radiofrequency ablation (RFA) — conventional thermalConventional thermal RFA uses electromagnetic energy to heat neural tissue, applying temperatures of about 60–90°C (commonly 67–85°C in trials) for lesioning (typical durations 60–120 seconds).

ModalitiesRFA includes conventional thermal, cooled (CRFA) and pulsed (PRF) modalities with differing lesion characteristics.

Clinical intentUsed to lesion targeted sensory nerve branches supplying a joint or region to reduce chronic pain when diagnostic blocks predict response.

Chemical neurolysis

Chemical neurolysis definitionInjection of neurolytic agents (e.g., phenol or alcohol) to intentionally destroy targeted nerve fibers to provide prolonged analgesia.

Clinical contextTypically considered when repeated diagnostic/therapeutic nerve blocks provide reliable but short-lived relief; used cautiously due to risks.

RisksPotential for neuritis, neuraxial spread, or unintended destruction of adjacent tissues; documented in literature and case reports.

Intercostal neuralgia — definition

Intercostal neuralgia definitionNeuropathic pain in the distribution of one or more intercostal nerves, often sharp, burning, or band-like, caused by thoracotomy, herpes zoster, trauma, or iatrogenic injury.

Clinical featuresPain may be constant or intermittent, exacerbated by movement, coughing, or respiration, and may include paresthesias.

Management contextEarly multimodal pain management reduces chronicity; neurolytic techniques considered for refractory cases.

Suprascapular nerve RFA — definition & context

Suprascapular nerve RFA definitionRFA targeting the suprascapular nerve, which supplies up to ~70% of shoulder sensory innervation, used for chronic shoulder pain management.

Target nervesOther targets include axillary, lateral pectoral, and subscapular nerves depending on pain distribution.

Use caseConsidered for chronic shoulder pain unresponsive to conservative measures; evidence limited and complications reported as generally minor.

Lateral branch RFA (SIJ) — definition

Lateral branch RFA (SIJ) definitionRFA targeting lateral branches of S1–S3 dorsal rami and the L5 medial branch to denervate the posterior sacroiliac joint complex.

Anatomical noteAnatomical variability of lateral branch pathways can limit consistency of outcomes; larger lesions may improve targeting but increase risk.

Responder ratesReported responder rates across studies range from ~32% to 89% depending on technique and selection.

Radiofrequency ablation (RFA) — general

RFA general definition and modalitiesRadiofrequency ablation (RFA) is a neuroablative modality using thermal energy; modalities include conventional/thermal, cooled (CRFA), and pulsed (PRF).

Therapeutic goalLesion targeted sensory nerve branches supplying joints to reduce chronic pain when diagnostic blocks indicate likely benefit.

Technique considerationsLesion size, probe type, and approach influence outcomes; specialty guidelines describe variable evidence across modalities.

Pericapsular nerve group (PENG) neurolysis

PENG neurolysis definitionPericapsular nerve group (PENG) neurolysis is an ultrasound-guided procedure targeting sensory nerves around the hip capsule; ethanol (95%) was used in the cited trial following a diagnostic PENG block.

Trial protocol noteOnly participants with >50% pain reduction after diagnostic PENG block proceeded to neurolytic intervention in the cited RCT.

OutcomesEthanol neurolysis in the trial showed significant pain reduction vs sham without observed neurological deficits over follow-up.

Genicular RFA / CRFA — definition

Genicular RFA / CRFA definitionGenicular nerve RFA (including cooled RFA) targets genicular branches (superomedial, superolateral, inferomedial) to treat knee OA pain; diagnostic low-volume genicular blocks may predict response.

Durability evidenceSmall studies report durability with 69% and 63% maintaining ≥50% pain reduction at 18 and 24 months in an extension cohort of CRFA.

Safety considerationsGenicular nerves lie near genicular arteries; vascular injury, septic arthritis, hematoma and skin burn are potential complications.

Plantar fasciitis — treatment pathway

Plantar fasciitis treatment pathway — first-lineStretching, ice, activity modification, weight loss, adaptive footwear, orthoses, NSAIDs, shock-absorbing inserts.

Second-line therapiesNight splints, steroid injections, walking cast when first-line measures fail.

When to consider ablative/surgicalSurgical or ablative methods may be considered after 6–12 months of failed first- and second-line therapies.

Radiofrequency ablation / neurotomy — definition

RFA / neurotomy definitionInterventional procedure applying thermal energy (conventional, cooled, or pulsed) to sensory nerves or articular branches to reduce chronic pain; selection guided by diagnostic blocks and clinical evaluation.

Modalities and aimsIncludes conventional thermal RFA, cooled RFA for larger lesions, and pulsed RFA for neuromodulation without destructive heating.

Clinical evidenceEvidence varies by indication; specialty guidelines support RFA in selected conditions (e.g., facet-mediated LBP, SIJ, knee OA) with differing strength.

Pulsed radiofrequency ablation — definition

Pulsed radiofrequency (PRF) definitionPRF delivers brief bursts of energy while maintaining tissue temperatures below 42°C, aiming to alter nociceptive signaling without thermal destruction.

Clinical parametersStudies report PRF parameters including temperatures 38–42°C, variable durations, voltages, and pulse widths.

Evidence contextPRF has shown short-term benefit in some trials but higher-quality data and long-term outcomes are limited.