ModifiedPremera BluecrossPolicy 7.01.565

Ablation of Peripheral Nerves to Treat Pain

Defines coverage and investigational stance for radiofrequency ablation, cryoneurolysis, and chemical neurolysis of peripheral nerves for various pain indications; intended for Premera BlueCross providers and claim reviewers.

Policy Summary

PayerPremera Bluecross

PolicyAblation of Peripheral Nerves to Treat Pain

Policy CodePolicy 7.01.565

Change TypeReplaced prior policy 7.01.154updated coverage determinations

Effective DateDec. 1, 2025

Next Review Date

Key ActionFollow documentation requirements and provide clinical records when requesting coverage; investigational procedures risk denial.

SourceLink

POLICY UPDATE CHANGES

Policy replaced prior policy 7.01.154 and republished as 7.01.565 with updated coverage determinations and related policy links.

Dec. 1, 2025Effective date

Nov. 10, 2025Last revised

3+Procedure types

CPT changesCoding updates

K163461FDA 510(k) cited

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Coverage Determinations

Radiofrequency ablation — Investigational

Policy coverage determinations (investigational designations):

RFA and indications investigational: Radiofrequency ablation of peripheral nerves to treat pain associated with knee osteoarthritis or plantar fasciitis is considered investigational. Radiofrequency ablation of peripheral nerves to treat pain associated with occipital neuralgia or cervicogenic headache is considered investigational.

From Policy Coverage Criteria.

Cryoneurolysis — Investigational

Cryoneurolysis investigational: Cryoneurolysis of peripheral nerves to treat pain associated with knee osteoarthritis or total knee arthroplasty is considered investigational. Cryoneurolysis of peripheral nerves to treat pain associated with occipital neuralgia or cervicogenic headache is considered investigational.

From Policy Coverage Criteria.

Chemical neurolysis — Investigational

Chemical neurolysis investigational: Chemical neurolysis (e.g., alcohol, phenol, glycerol) of the peripheral nerves to treat pain associated with knee osteoarthritis or plantar fasciitis is considered investigational.

From Policy Coverage Criteria and Description noting limited evidence.

Other peripheral nerve ablation — Investigational

Other peripheral nerve ablations investigational: Ablation of peripheral nerves to treat pain is considered investigational in all other conditions, including but not limited to intercostal neuralgia (except facet joint pain per related policies).

From Policy Coverage Criteria.

Investigational / Not covered statements (history)

Policy statements in history indicate investigational status for certain ablative procedures and specific indications

Investigational ablative procedures (2018 entry): Ablative procedures of peripheral nerves to treat pain for all indications, including but not limited to plantar fasciitis or knee osteoarthritis, are considered investigational (cooled radiofrequency ablation, cryoneurolysis, radiofrequency ablation).

From 08/01/18 history entry.

Chemical neurolysis (2024 addition): Chemical neurolysis of the peripheral nerves to treat pain associated with knee osteoarthritis or plantar fasciitis is considered investigational.

From 03/01/24 history entry.

Facet joint pain is explicitly excluded from the investigational listings in this policy; management of facet-mediated pain is addressed in related medical policies (see Related Medical Policies).

There is no national coverage determination (NCD) cited for these peripheral nerve ablation procedures in the Medicare NCD database within this policy; FDA device 510(k) clearances are described separately under Regulatory Status.

The policy considers ablative procedures applied to peripheral nerves investigational for multiple peripheral nerve pain indications. Examples called out include pain associated with plantar fasciitis, knee osteoarthritis, occipital neuralgia, and cervicogenic headache; cryoneurolysis and radiofrequency procedures for these indications are listed as investigational in the coverage criteria and historical policy entries.

Any peripheral nerve ablation indication that is not specifically supported by evidence and explicitly listed as covered in this policy is considered investigational and therefore not medically necessary under this policy.

Policy history entries record that certain ablative procedures have been labeled investigational in prior reviews — examples include cooled radiofrequency ablation, cryoneurolysis (cryoablation), conventional radiofrequency ablation, and, as of 03/01/24, chemical neurolysis for specified indications such as knee osteoarthritis or plantar fasciitis.

Coding and Device Listings

Listed CPT CodesCPT

0441T	Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
64620	Destruction by neurolytic agent, intercostal nerve
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

Listed HCPCS CodesHCPCS

C9808	Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)
C9809	Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying Medicare non- opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)

Device 510(k) clearances (Table 3 and text)mixed

K053082	SInergy/Baylis Pain Management Probe clearance
K111576	NeuroTherm NT 2000 clearance
K133453	iovera (cryoneurolysis device) clearance
K163236	COOLIEF Cooled Radiofrequency Kit clearance
K163461	COOLIEF Cooled RF Probe clearance
K190256	Rulo Radiofrequency Lesion Probe clearance
K222281	Intracept Intraosseous Nerve Ablation System clearance
K220122	Apex 6 Radiofrequency Lesion Generator clearance

Referenced CPT/HCPCS codes (history)mixed

0441T	code referenced as removed/added in history
64620	CPT code added (per history 12/01/21)
64624	CPT code added (effective 1/1/20; referenced multiple times)
64632	CPT code added (03/01/24)
64999	code referenced as removed
C9808	HCPCS code added (01/01/25)
C9809	HCPCS code added (01/01/25)

RFA electrode application time/temperature — technical parameters for RFA modalities

Standard RFA applicationElectrode heated to 70–90°C for 90–130 seconds to produce a thermal lesion with greater adjacent tissue injury.

Pulsed RFA applicationNon‑ablative pulsed RF (20 ms pulses every 30 seconds reported) producing lower temperatures (~42°C) thought to limit tissue injury and provide shorter duration relief.

Cooled RFA applicationWater‑cooled probe produces greater energy delivery with tissue temperatures around ~60°C to create a larger lesion while limiting thermal spread.

Coding-related notes

Codes listed in policy (examples)Codes such as 0441T, 64620, 64624, 64632, C9808, C9809 are referenced in coding and history entries — verify current code set when submitting claims.

Provider Actions and Authorization Considerations

Billing Rule

Codes subject to policy review

Providers should be aware that specific CPT and HCPCS codes for peripheral nerve ablation and cryoneurolysis are subject to policy review and may affect coverage determinations. Verify the codes used when submitting claims or prior authorization requests.

Affected CPT codes include, but are not limited to: 0441T; 64620; 64624; 64632; 64640.
Affected HCPCS codes include C9808 and C9809 (added 01/01/25).
Codes and descriptions are subject to change; always confirm current code sets.

Prior Authorization

Coding updates may affect prior authorization

Coding updates can change prior authorization handling. Verify the current CPT/HCPCS code set and any payer-specific prior authorization requirements at the time of request.

Conservative Treatment and Diagnostic Block Requirements

Documented prior conservative therapy — requirement of >6 months of conservative therapy.

Documented prior conservative therapy required: For device indications referenced in this policy (e.g., COOLIEF cooled RF probe), conservative therapy, including medication, for more than 6 months is specified prior to device use.> 6 months

From Regulatory Status describing device indication.

Procedural Definitions and Device Notes

Standard RFA — technical definition

Temperature rangeElectrode heats tissue to 70–90°C.

Application durationTypical application duration 90–130 seconds.

Effect on tissueProduces a thermal lesion with more adjacent tissue injury compared with lower‑temperature techniques.

Pulsed RFA — technical definition

MechanismNon‑ablative pulsed RF delivered as short pulses rather than continuous heat.

TemperatureGenerates lower temperatures (approximately 42°C).

Clinical effect

Imaging and Guidance for Procedures

Documentation Required

Document imaging and guidance used for genicular procedures

Some genicular nerve trials used fluoroscopic or ultrasound guidance and cooled RFA trials used anesthetic nerve blocks with image guidance; document the imaging/guidance technique used in the procedure note when applicable.

Document modality used (fluoroscopy or ultrasound) and any anesthetic diagnostic block performed under image guidance.
Record procedural details consistent with study methods if using evidence to support coverage requests.

Note

Record imaging modality; no explicit imaging mandate in policy

Studies and device reports include both fluoroscopic and ultrasound guidance comparisons for genicular procedures, but the policy does not state an explicit imaging requirement; record whichever image guidance was used.

Include imaging modality in operative/procedure documentation; policy does not mandate a specific imaging method.

Frequency and Repeat Procedure Considerations

Cryoneurolysis and RFA — frequency limits

Frequency limits statedNo explicit frequency limits for cryoneurolysis or RFA are specified in the cited frequency limits section of the document.

Clinical trials noteRCTs and registry studies for cryoneurolysis report unresolved technical issues (optimal number/duration of applications), indicating frequency decisions vary by study.

Billing implicationAbsent explicit policy frequency limits, providers should document clinical rationale and follow payer billing guidance.

Frequency-limits placeholder

Placeholder entryInventory entry present noting frequency‑limits section but no explicit summarized limits in policy excerpts.

Actionable step

Services Not Covered

NOT COVERED: Radiofrequency ablation, cryoneurolysis, and chemical neurolysis of peripheral nerves to treat pain associated with knee osteoarthritis, plantar fasciitis, occipital neuralgia, cervicogenic headache, intercostal neuralgia, pain after total knee arthroplasty (TKA), and other peripheral nerve pain indications listed in the policy are considered investigational and are not covered.

Background and Scope

Background: Peripheral nerve ablation techniques (including radiofrequency ablation, cryoneurolysis, and chemical neurolysis) are procedures intended to interrupt pain signal transmission by producing focal nerve injury or degeneration. The modalities differ in mechanism — for example, cryoneurolysis uses extreme cold to cause Wallerian degeneration with subsequent nerve regeneration, while chemical neurolysis applies agents such as alcohol or phenol to produce long‑lasting interruption of neural transmission — and the evidence for these peripheral applications is limited and heterogeneous.

Policy Summary

PayerPremera Bluecross

PolicyAblation of Peripheral Nerves to Treat Pain

Policy CodePolicy 7.01.565

Change TypeReplaced prior policy 7.01.154updated coverage determinations

Effective DateDec. 1, 2025

Next Review Date

Key ActionFollow documentation requirements and provide clinical records when requesting coverage; investigational procedures risk denial.

SourceLink

On This Page

Prior authorization noteNo explicit prior authorization requirement is specified in the cited sections; however, listed CPT/HCPCS codes would be subject to payer prior‑authorization processes per provider guidance.

Coding history impactPolicy history documents code additions/removals (e.g., 64624 added 1/1/20; C9808/C9809 added 1/1/25); confirm up‑to‑date codes before billing.

Coding changes noted in policy history (e.g., addition of CPT 64624, 64632 and HCPCS C9808/C9809).
Prior authorization workflows may reference specific codes; confirm requirements when submitting.

Denial Risk

Investigational procedures — denial risk

Ablation procedures designated as investigational in this policy may be denied. Providers should expect denial risk for indications listed as investigational (e.g., RFA or cryoneurolysis for knee osteoarthritis, plantar fasciitis, occipital neuralgia, cervicogenic headache, and other listed conditions).

Radiofrequency ablation, cryoneurolysis, and chemical neurolysis of peripheral nerves are listed as investigational for multiple indications in this policy.
Investigational services are subject to denial based on the policy's coverage statements.

Note

No explicit denial triggers in this section

This section does not itself create explicit individual denial triggers beyond the investigational designations; review the full policy criteria and documentation requirements for specific coverage determinations.

No additional explicit denial triggers are specified in this section; denials will follow the policy's investigational and coverage criteria.
Providers must follow documentation requirements and policy criteria links when submitting requests.

Documentation Required

Documented positive response to diagnostic nerve block

For FDA-cleared device indications (e.g., COOLIEF cooled RF probe), documentation of a positive response to a diagnostic genicular nerve block is required: >50% reduction in pain.

Documented >50% reduction in pain after a diagnostic genicular nerve block is part of the FDA-cleared indication for certain devices.
Include results of diagnostic nerve blocks in the clinical record submitted for review.

Documentation Required

Supporting documentation

Supply supporting clinical documentation consistent with the policy and the literature base when requesting coverage. This includes prior treatments tried, diagnostic block responses, imaging, and device-specific indications if applicable.

Provide clinical notes documenting conservative therapy attempts, duration of symptoms, and objective findings.
Include diagnostic block results, imaging confirming osteoarthritis when applicable, and clear documentation tying symptoms to the targeted nerve distribution.
Policy is based on literature review and references; furnish documentation consistent with those standards.

Note

Conservative therapy described

Conservative therapies are expected antecedent treatments prior to considering ablative procedures. Examples include topical agents, systemic medications, and diagnostic/therapeutic nerve blocks.

Topical medications: capsaicin cream, lidocaine gels.
Systemic medications: e.g., gabapentin.
Diagnostic or therapeutic nerve blocks (used both diagnostically and as conservative management).
FDA-cleared indications for some devices reference prior conservative therapy (including medication) for >6 months.

Note

FDA indication references prior conservative therapy

Note the FDA-cleared indications may explicitly require prior conservative therapy before use of a device, reinforcing the expectation that conservative measures (including medication) be tried and documented.

Example: COOLIEF indication specifies >6 months of conservative therapy, including medication, and radiologically-confirmed osteoarthritis with positive diagnostic block response.
Ensure documentation demonstrates the conservative therapy timeline and components when applicable.

Thought to limit tissue injury and may provide shorter‑duration pain relief compared with standard RFA.

Cooled RFA — technical definition

Cooling mechanismUses a water‑cooled probe to deliver more energy at the target while limiting heat diffusion to adjacent tissue.

Tissue temperatureReported target tissue temperature approximately 60°C.

Lesion characteristicsCreates a larger lesion with limited thermal spread and potential for longer‑term relief; device FDA clearances (e.g., COOLIEF) reference cooled RFA for genicular nerves.

Cryoneurolysis — technical definition

Temperature rangeApplication of extreme cold in the range of approximately -20°C to -100°C.

Mechanism of injuryCauses Wallerian (anterograde axonal) degeneration with disruption of nerve conduction while preserving perineural/epineural structures.

Duration of effectNerve regeneration and recovery of function typically occurs in about 3–5 months.

Chemical neurolysis — technical definition

Agents usedChemical agents include phenol, ethyl alcohol, glycerol, or hypertonic saline applied to a nerve.

Intended effectCreates a long‑lasting or permanent interruption of neural transmission for pain relief.

Evidence noteEvidence for use in conditions like plantar fasciitis is limited; studies for knee OA are small and nonrandomized, requiring further research.

COOLIEF Cooled Radiofrequency Probe (K163461) — regulatory

Device and clearanceCOOLIEF Cooled Radiofrequency Probe (K163461) cleared by FDA via 510(k) to create lesions in nervous tissue.

Indication specificsIndication includes creating radiofrequency lesions of the genicular nerves for management of moderate to severe knee pain >6 months with conservative therapy and a positive diagnostic genicular nerve block (>50% pain reduction).

Manufacturer historyCleared in 2017 (Avanos, previously Halyard Health) per policy regulatory summary.

Interventions described as investigational in policy history

Investigational procedures listed in historyPolicy history entries document that cryoneurolysis, cooled RFA, RFA, and chemical neurolysis have been described as investigational for various peripheral nerve pain indications.

Implication for coverageProcedures labeled investigational in history are treated as not medically necessary for the listed indications per policy stance.

DocumentationSee history entries (08/01/18 onward) and 03/01/24 addition for chemical neurolysis investigational status.

Documentation Required

No explicit policy imaging requirement — document technique used

Imaging requirements are noted in study methods but the cited inventory entry provides no explicit policy imaging requirement; follow the procedure record and documentation links in the full policy.

If relying on evidence that used specific imaging or guidance, document those details in the record to support a coverage discussion.

Verify any practice‑specific or payer frequency rules during authorization and claims submission due to lack of explicit policy limits.

Historical contextPolicy history documents multiple annual reviews but has not added explicit frequency limits for these procedures through 2025.