EmblemHealth radiofrequency ablation Coverage Update

Coverage Criteria

Initial Therapy Criteria

Covered when ALL of the following are met

Primary coverage criteria for medial branch RFA: Member has moderate to severe cervical, thoracic, or lumbar spinal pain; pain is secondary to facet joint origin demonstrated by the absence of nerve root compression and radicular pain; neuroradiologic studies do not confirm disc herniation, infection, or tumor; pain refractory for a 6-month period and has failed to respond to 3 months of conservative management (e.g., NSAIDs/opioids, chiropractic/physical therapy, home exercise); demonstration of symptom relief after 2 controlled diagnostic medial branch blocks performed using an alternating short- and long-acting anesthetic protocol with no IV sedation or opioids2 diagnostic medial branch blocks; 6 months refractory pain; 3 months conservative care

See Intracept criteria for intraosseous basivertebral nerve ablation

Continuation / Repeat Therapy

Repeat RFA covered when ALL of the following are met

Repeat RFA criteria: Prior RFA treatment was successful defined as >=50% pain reduction in conjunction with functional improvement; maximum of 2 repeat RFA procedures over a 12-month period per side and level<=2 procedures per 12 months per side/level; >=50% pain reduction

Requests beyond the first year will be reviewed by a medical director

Intracept / Basivertebral Nerve Ablation Criteria

Intracept (intraosseous basivertebral nerve ablation) coverage (Commercial and Medicare) when ALL of the following are met

Intracept criteria: Skeletal maturity; chronic low back pain for at least 6 months; failure to respond to 3 months of conservative management (e.g., NSAIDs/opioids, chiropractic/physical therapy, home exercise); vertebrogenic back pain evidenced by Type 1 or Type 2 Modic changes on MRI involving the endplates between L3 and S16 months CLBP; 3 months conservative care; Modic Type 1 or 2 MRI findings

Procedure billing uses CPT codes 64628 (first 2 vertebral bodies) and 64629 (each additional vertebral body) for Commercial and Medicare

Use of thermal radiofrequency ablation (RFA) is limited to destruction of the medial branch nerve for facet-mediated spinal pain. Procedures that apply thermal RFA to any other spinal structure are considered investigational and not covered. Denervation procedures directed at the sacroiliac joint are considered experimental/investigational and are not covered. Non-thermal radiofrequency modalities for medial branch ablation—including chemical approaches, low‑grade thermal techniques, and pulsed radiofrequency (CPT 64625)—are not covered.

Repeat RFA may be considered medically necessary only when the prior treatment was successful. The policy limits repeat thermal medial branch RFA to a maximum of 2 procedures over a 12‑month period per side and level (i.e., no more than 2 procedures per year) and requires prior success defined as ≥50% pain reduction in conjunction with functional improvement. Requests for treatment beyond the first year will be reviewed by a medical director.

Members who have a history of spinal fusion surgery at the vertebral level being treated are excluded from coverage for medial branch RFA at that level. The presence of prior fusion at the target vertebral level precludes coverage of thermal RFA directed to medial branch nerves at that same level.

Long‑term, repeated, or maintenance RFA beyond the policy frequency limits is considered not medically necessary. Specifically, the policy does not support treatment per level per side within a 6‑month period, more than 2 treatments per year, or ongoing maintenance RFA without documented prior success. Requests for treatments beyond the first 12 months or that fall outside these protocols will be reviewed by a medical director.

Additionally, a repeat RFA is considered medically necessary only when prior RFA achieved success defined as ≥50% pain reduction with functional improvement. The policy lists several procedures and technologies (e.g., automated percutaneous lumbar discectomy, coblation nucleoplasty, cryoneurolysis, laser ablation/discectomy, intradiscal radiofrequency modalities) as investigational and not medically necessary when proposed as alternatives or maintenance strategies.

Conservative Therapy Requirements

Conservative Treatment Requirement

Conservative management must include ALL of the following prior to consideration of RFA or Intracept:

Conservative care trial: Trial of conservative therapies such as nonsteroidal anti-inflammatory drugs or opioids, chiropractic therapy or physical therapy, and a home exercise programMinimum 3 months

Failure to respond to a 3-month conservative management trial is required prior to RFA; Intracept also requires failure of a 3-month conservative trial

Frequency and Procedural Limits

Radiofrequency ablation (medial branch) — Frequency limits

Frequency limitMaximum of 2 procedures over a 12-month period per side and level (no more than 2 procedures per year)

ApplicabilityApplies to thermal RFA of spinal medial branch nerves; repeat treatments beyond limits require medical director review

Not medically necessaryTreatment per level per side within a 6-month period and >2 treatments per year are not considered medically necessary

Exclusion noteMembers with a history of spinal fusion at the vertebral level being treated are excluded

Medial branch RFA — Per-visit procedural limits

Per-visit level limitRFA allowed on a single visit for up to 3 facet levels

Coding

Procedure CodesCPT

62263	Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means catheter) including radiologic localization (includes contrast when administered) , multiple adhesiolysis sessions; 2 or more days (Medicare Only)
62264	Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means catheter) including radiologic localization (includes contrast when administered), single session (Medicare Only)
64628	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Commercial and Medicare only)
64629	Thermal destruction of intraosseous basivertebral nerve; including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) (Commercial and Medicare Only)
64633	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64635	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636	Destruction by neurolytic agent; paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

ICD-10 DiagnosesICD-10

M12.88	Other specific arthropathies, not elsewhere classified, other specified site
M47.11	Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12	Other spondylosis with myelopathy, cervical region
M47.13	Other spondylosis with myelopathy, cervicothoracic region
M47.14	Other spondylosis with myelopathy, thoracic region
M47.15	Other spondylosis with myelopathy, thoracolumbar region
M47.16	Other spondylosis with myelopathy, lumbar region
M47.811	Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812	Spondylosis without myelopathy or radiculopathy, cervical region
M47.813	Spondylosis without myelopathy or radiculopathy, cervicothoracic region

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Repeat RFA success threshold

Success threshold for repeat RFA>= 50% pain reduction in conjunction with functional improvement

Documentation requirementPrior RFA must have documented clinical improvement (pain reduction and functional gains) to qualify for repeat treatment

Frequency conditionEven with prior success, repeat treatments limited to a maximum of 2 procedures per 12 months per side/level

Review for extensionsRequests beyond the first year or outside limits will be reviewed by a medical director

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for medial branch radiofrequency ablation (RFA). The treating physician or primary care provider must submit a prior authorization request so the Plan can review medical necessity before the procedure is performed.

A complete prior authorization request must be submitted before scheduling medial branch RFA
Failure to obtain preauthorization may result in denial of coverage or lack of payment

Documentation Required

Documentation Submission Requirement

All required supporting clinical documentation must be submitted with the preauthorization request. If the provider fails to submit the necessary documentation, the Plan will be unable to properly review the request and this may prevent approval or coverage.

Submit complete medical records including history, physical examination, and neuroradiologic studies

Imaging and Procedural Guidance

Note

Include neuroradiologic studies and use fluoroscopy or CT guidance

Provide neuroradiologic studies to exclude disc herniation, infection, or tumor and perform diagnostic medial branch blocks and RFA under imaging guidance (fluoroscopy or CT) per the CPT descriptions.

Diagnostic medial branch blocks must follow the alternating short- and long-acting anesthetic protocol with no IV sedation or opioids.
Imaging guidance (fluoroscopy or CT) is indicated for both diagnostic blocks and medial branch RFA and is referenced in the CPT code descriptions (e.g., 64633–64636).

Background

Radiofrequency ablation (RFA) is a percutaneous procedure that uses radiowave‑induced heat to create a lesion in a spinal sensory nerve (commonly the medial branch nerve) to interrupt transmission of pain signals and relieve facet‑mediated spinal pain. It is intended for patients with moderate to severe cervical, thoracic, or lumbar facet joint pain who have exhausted conservative measures and have diagnostic confirmation via controlled medial branch blocks.

Diagnostic medial branch blocks and RFA procedures should be performed with appropriate imaging guidance (fluoroscopy or CT) and follow standard block protocols (alternating short‑ and long‑acting local anesthetic, without IV sedation or opioid administration during diagnostic blocks).

Definitions

Radiofrequency ablation (RFA) — Definition and alternate names

DefinitionRadiofrequency ablation (RFA) is a percutaneous treatment using radiowave-induced heat to create a lesion in a spinal sensory (medial branch) nerve to relieve pain by interrupting transmission of pain signals

Alternate namesFacet neurotomy; facet rhizotomy; articular rhizolysis

Procedure intentIntended for patients with facet-mediated cervical, thoracic, or lumbar spinal pain who have failed conservative measures and had diagnostic confirmation

ExclusionsThermal RFA applied to spinal structures other than medial branch nerves is considered investigational and not covered

Not Covered

Non‑thermal radiofrequency modalities and several other variations of spinal radiofrequency procedures are not covered. This includes pulsed radiofrequency techniques (listed separately), chemical or low‑grade thermal RF approaches for medial branch ablation, and radiofrequency thermocoagulation procedures applied to indications such as chronic coccydynia. The policy also identifies a range of procedures as investigational and not covered, including automated percutaneous lumbar discectomy, coblation/nucleoplasty, cryoneurolysis, laser ablation/discectomy, percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), intradiscal electrothermal annuloplasty (IDET), epiduroscopy/epidural endoscopy procedures, intervertebral disc biacuplasty, and other listed technologies.

The Intracept intraosseous basivertebral nerve system is addressed separately in the policy and, when indicated, may be covered under specific criteria for Commercial and Medicare members; however, other intraosseous or investigative RF approaches remain investigational unless explicitly listed as covered.

OpenPayer

Radiofrequency Ablation for Spinal Pain