Neuroablation for Pain Management
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Defines medical necessity, limitations, and exclusions for neuroablative procedures used to treat pain for Priority Health members; applies to providers requesting coverage determinations.
Removed the prior limit of two RFA procedures per year and requirement for medical review beyond two.
Conventional sacroiliac joint radiofrequency ablation moved from investigational to medically necessary when medical necessity criteria are met; Prior Authorization required.
Updated investigational/experimental/uncertain status: cooled radiofrequency ablation remains investigational/uncertain for all indications except knee osteoarthritis.
Added medical necessity criteria for repeat radiofrequency ablation for back and neck pain.
Expanded not medically necessary to include nerve cryoablation and cryodenervation.
New policy template standardization with Policy Scope, FDA/Regulatory, Medical/Professional Society Guidelines, and CMS sections.
Coverage Criteria and Policy Stance
Conventional RFA — initial
Conventional Radiofrequency Ablation (RFA) for Back and Neck Pain is considered medically necessary when ALL of the following are met:
Repeat RFA — spine
Repeat Radiofrequency Ablation for Back and Neck Pain is considered medically necessary when ALL of the following are met:
Intraosseous Basivertebral Nerve RFA
Intraosseous Basivertebral Nerve Radiofrequency Ablation is considered medically necessary when ALL of the following are met:
Sacroiliac joint RFA
Sacroiliac (SI) Joint Radiofrequency Ablation is considered medically necessary when ALL of the following are met:
Repeat SI joint RFA
Repeat SI joint RFA is considered medically necessary when ALL of the following are met:
Sacroiliac (SI) joint lateral branch RFA — medical necessity
Covered when ALL of the following are met for conventional thermal SIJ lateral branch RFA:
Cooled RFA is considered not medically necessary/investigational; pulsed RFA is investigational and not medically necessary for any indication.
Intracept (basivertebral nerve) RFA — medical necessity
Covered when ALL of the following are met for Intracept BVN ablation:
Evidence includes randomized sham-controlled trials with mixed ITT/PP results and longer-term follow-up showing some durable improvements in subsets of patients.
General medical necessity and plan applicability
Coverage is conditional on medical necessity and member-specific benefit details.
If CMS has a Medicare determination, that governs Medicare members.
Coverage stance updates
Policy-level coverage stance changes and additions
Exact medical necessity criteria are located in other sections of the policy.
Requests for cooled RFA outside the knee OA exception are non-covered/deniable as investigational.
Specific repeat procedure criteria are in other sections of the policy.
The policy classifies cooled radiofrequency ablation (CRFA) (except when performed for knee osteoarthritis per a separate Priority Health policy) and cryoneurolysis/cryoneuroablation as not medically necessary/experimental or investigational for routine pain management. The rationale cites limited, heterogeneous evidence with short-term or inconsistent benefit and lack of standardized patient selection, procedural parameters, and durable long-term outcomes to support routine coverage outside established, indication-specific policies. (CRFA evidence is characterized by variable techniques, non-sham comparators, and absence of standardized diagnostic pathways; cryoneurolysis shows transient benefit in some settings with uncertainty about sustained outcomes.)
Intercostal nerve cryoablation (INC) is explicitly described as a regional cryoanalgesia technique used for perioperative thoracotomy pain, but current evidence and major society guidance raise safety and long-term outcome concerns. Accordingly, intercostal nerve cryoablation is considered experimental, investigational, and/or unproven for routine management of post‑thoracotomy pain and is not supported for routine coverage.
The policy maintains that pulsed radiofrequency ablation (PRF) is investigational and not medically necessary for any indication due to limited, inconsistent evidence, heterogeneous techniques, and lack of durable benefit. Separately, cooled RFA applied to the sacroiliac joint (cooled SIJ RFA) is considered not medically necessary/investigational when billed or reported as a cooled procedure because evidence does not demonstrate incremental clinical benefit over conventional thermal SIJ lateral branch RFA.
When cooled RFA techniques are used for sacroiliac denervation, claims billed with the SIJ denervation code 64625 and reported as COOLED RFA are specifically not covered. Providers should report procedural codes consistent with conventional thermal RFA when criteria for covered SIJ lateral branch RFA are met; cooled-RFA reporting for SIJ denervation may be denied as not medically necessary.
The policy explicitly expands exclusions to list nerve cryoablation and cryodenervation (examples include intercostal nerve cryoablation and other cryoanalgesia procedures) as not medically necessary. This expansion reflects the limited and heterogeneous evidence for durable benefit and aligns cryo-based peripheral nerve ablations with the investigational stance described elsewhere in the document.
Across modalities, the evidence does not demonstrate consistent, durable clinical benefit sufficient for routine coverage: cooled RFA (outside knee OA) is limited by heterogeneity in patient selection, diagnostic protocols, and procedural technique with no standardized parameters or robust sham-controlled durability; pulsed RFA lacks reproducible, long-term improvements and standardized methods; and cryoneurolysis/cryoneuroablation generally shows only short‑term or perioperative analgesia with attenuation of benefit and uncertain longer‑term outcomes. For these reasons the policy treats these modalities as investigational/not medically necessary for routine pain management.
Because pulsed RFA does not reliably produce neurodestructive lesions and existing studies are small, heterogeneous, and short-term, the policy concludes that pulsed radiofrequency ablation is not medically necessary for any indication. The limited and inconsistent evidence base and lack of guideline endorsement underpin this determination.
Cooled sacroiliac joint RFA is considered investigational/not medically necessary because randomized and observational data have not demonstrated clear incremental benefit over conventional thermal SIJ lateral branch RFA. Operationally, claims for SIJ denervation billed with cooled-RFA technique (e.g., reported as COOLED RFA) may be denied; providers should follow conventional SIJ RFA coding and prior authorization requirements when applicable.
Treatments classified as experimental, investigational, or unproven under this policy are excluded from coverage unless an individual case review is requested and prior plan approval is obtained. Such exception requests are adjudicated by a Priority Health medical director or clinical pharmacist and require submission of supporting clinical documentation demonstrating why the investigational approach may be appropriate for the specific member.
The policy explicitly lists nerve cryoablation and cryodenervation (including intercostal nerve cryoablation) as not medically necessary. This exclusion is grounded in the limited durability of benefit, heterogeneity of evidence, and professional society guidance that does not endorse routine use of these cryo-based interventions for chronic pain indications.
Coding and Billing
| G89.21-G89.29 | Chronic pain, not elsewhere classified |
| G89.3 | Neoplasm related pain (acute) (chronic) |
| G89.4 | Chronic pain syndrome |
| M54.03-M54.09 | Panniculitis affecting regions of neck and back |
| M54.5-M54.9 | Other back pain |
| M62.830 | Muscle spasm of back |
| R52 | Pain, unspecified |
| 22899 | Unlisted procedure, spine (used to report cooled radiofrequency ablation or Intracept when reported as unlisted) |
| 64999 | Unlisted procedure, nervous system (when used to report pulsed RFA for spinal pain) |
| 64620 | Destruction by neurolytic agent, intercostal nerve |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, single facet |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, each additional facet joint |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint |
| 22899 | Unlisted procedure, spine (when used to report cooled radiofrequency ablation or Intracept procedure) |
| 64999 | Unlisted procedure, nervous system (when used to report pulsed RFA for spinal pain) |
| 64620 | Destruction by neurolytic agent, intercostal nerve |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed |
| 64625 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (Not covered when billed for COOLED RFA) |
| 64628 | Thermal destruction of intraosseous basivertebral nerve; first 2 vertebral bodies, lumbar or sacral |
| 64629 | Thermal destruction of intraosseous basivertebral nerve; each additional vertebral body, lumbar or sacral |
| 64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, single facet |
| 64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; cervical or thoracic, each additional facet joint |
| 64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance; lumbar or sacral, single facet joint |
| 64640 | Destruction by neurolytic agent, lumbar or sacral, each additional facet joint |
| 0440T | Ablation, percutaneous, cryoablation, including image guidance; upper extremity distal/peripheral nerve |
| 0441T | Ablation, percutaneous, cryoablation, including image guidance; lower extremity distal/peripheral nerve |
| 0442T | Ablation, percutaneous, cryoablation, including image guidance; nerve plexus or truncal nerve (e.g., brachial plexus, pudendal nerve) |
| C9808 | Nerve cryoablation probe including probe and disposable system components (non-opioid medical device qualifying under section 4135 of the CAA, 2023) |
| C9809 | Cryoablation needle including needle/tip and disposable system components (non-opioid medical device qualifying under section 4135 of the CAA, 2023) |
| No codes listed |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization must demonstrate medical necessity (diagnostic blocks, conservative therapy, imaging)
When prior authorization is required, submit documentation that demonstrates the requested neuroablative procedure meets medical necessity criteria — e.g., diagnostic block results meeting the policy responder thresholds (each medial branch or SIJ diagnostic block showing ≥50% pain relief), evidence of prior conservative therapy and its duration, and imaging excluding alternate structural causes.
- Diagnostic blocks: two medial branch blocks with >50% pain relief for facet RFA; SIJ blockade showing ≥50% improvement in pain and function.
- Conservative therapy: document trial and failure of appropriate non-surgical management (see conservative care callouts).
- Imaging/clinical evaluation to exclude alternative causes (disc herniation, spinal stenosis, tumor, infection, etc.).
Prior authorization required when billing neuroablation CPT/HCPCS codes
Prior authorization is required when billing the listed neuroablation CPT/HCPCS codes (e.g., 64625, 64628, 64629, 22899, 64999 and other codes in the policy) to confirm that the member meets the policy's medical necessity criteria.
Prior authorization processes — consult Priority Health Provider Manual
Follow the Priority Health Provider Manual and plan-specific prior authorization processes — some drugs, devices, services, or procedures may require PA and submission requirements vary by product.
- Check the Provider Manual for required forms, submission channels, and timelines.
- If individual case review is needed for investigational treatments, obtain prior plan approval.
Prior authorization required for conventional SIJ lateral branch RFA
Conventional sacroiliac joint radiofrequency ablation now requires prior authorization when medical necessity criteria are met; submit a PA demonstrating the criteria for SIJ RFA have been fulfilled.
- Document positive SIJ provocation tests and image-guided diagnostic block response (≥50% improvement in pain and function).
- Include prior conservative management documentation and imaging excluding alternate causes.
Conservative therapy must be documented before authorization
Document a trial and failure of conservative therapy for the minimum durations specified by the policy before seeking authorization for neuroablative procedures.
- Intracept (basivertebral nerve RFA): failure of at least 6 months of conservative nonsurgical care (analgesics, anti-inflammatories, muscle relaxants, exercise, spinal manipulation, physical therapy or home exercise).
- SIJ RFA: failed minimum of 3 months of appropriate conservative management (physical therapy, pharmacologic therapy, and/or activity modification).
Intracept requires ≥6 months of documented conservative nonsurgical care before consideration
For Intracept (BVN ablation), at least six months of documented conservative nonsurgical care is required prior to consideration and submission for authorization.
- Conservative care examples: analgesics, anti-inflammatory drugs, muscle relaxants, exercise, spinal manipulation, physical therapy, home exercise programs.
- Include duration and specific therapies tried in the PA submission.
Consult member-specific plan documents for coverage applicability
Coverage is subject to the member's specific benefits and group-specific plan documents; consult the applicable plan documents as they supersede this policy when conflicts exist.
- For self-funded (ASO) and individual policies, verify provisions in the member's plan document.
- For Medicare members, CMS determinations govern when applicable.
Removed prior numeric limit of two RFA procedures per year
The prior numeric limit of two RFA procedures per year has been removed — do not use a 'two-per-year' cap as a basis for denial or review; continue to apply medical necessity and frequency-interval criteria for repeat procedures.
- Apply repeat-procedure criteria (e.g., minimum intervals) rather than a numeric annual cap.
- Document duration of prior benefit when requesting repeat RFA per repeat criteria.
Required clinical documentation with PA: presentation, conservative therapy, diagnostic block details
Submit detailed clinical documentation with PA or claim supporting medical necessity: the patient's presentation, prior conservative therapy and duration, results of diagnostic blocks including agents used and percent relief, and imaging excluding alternative causes.
- For diagnostic blocks report the anesthetic agents used, timing, and percent pain relief (policy thresholds: >50% for medial branch blocks and ≥50% for SIJ blocks).
- For repeat procedures document prior pain relief magnitude and duration (e.g., ≥50% relief lasting ≥12 weeks for repeat spinal RFA).
SIJ lateral branch RFA — required documentation (provocation tests, diagnostic block ≥50%)
For SIJ lateral branch RFA, include clinical exam findings (positive SIJ provocation tests), image-guided diagnostic blockade results showing ≥50% improvement in pain and function for L5 dorsal ramus and S1–S3 lateral branches, and documentation of prior conservative management.
- List which provocative tests were positive (high thrust OR compression plus ≥2 additional tests such as Gaenslen's, distraction, FABER, posterior provocation).
- Describe the image-guided block technique, agent(s) used, and the measured change in pain/function (≥50%).
Intracept (BVN) authorization documentation: chronic LBP ≥6 months, failed ≥6 months conservative care, MRI Modic changes
For Intracept BVN ablation requests, document chronic low back pain ≥6 months, failure of ≥6 months conservative nonsurgical care, lumbar MRI demonstrating Modic Type 1 or Type 2 endplate changes at target levels, and procedural plan including fluoroscopic intraosseous access to L3–S1.
- Include MRI report(s) describing Modic Type 1 or Type 2 changes corresponding to treated vertebral levels.
- Describe conservative therapies attempted, their durations, and lack of adequate response.
Submit PA requests with documentation proving medical necessity for initial or repeat RFA
When prior authorization is required, submit the PA request with documentation that proves medical necessity and supports all required criteria for initial or repeat procedures; failure to provide required documentation or omission of PA when required may result in denial.
- Include copies of diagnostic block records, conservative care notes, imaging reports, and procedure notes from prior RFA if requesting repeat ablation.
- If the request involves an investigational technology, note that individual case review and prior plan approval are required for possible exception.
Investigational technologies (cooled RFA, pulsed RFA, cryoneurolysis) — likely denial risk
Requests for cooled RFA, pulsed RFA, or cryoneurolysis (including intercostal nerve cryoablation) will generally be denied as these are considered experimental, investigational, or not medically necessary per policy.
- Cooled RFA is investigational for all indications except knee osteoarthritis (see separate knee OA policy No. 91571).
- Pulsed RFA and cryoneurolysis/cryoablation (including INC) are listed as not medically necessary.
Cooled SIJ RFA billed as cooled technique is not covered — denial risk
Cooled SIJ RFA is considered not medically necessary/investigational; claims billed using the SIJ RFA code (64625) for a cooled RFA technique may be denied as not covered when billed as COOLED RFA.
- If billing 64625, indicate the technique; cooled technique billed as cooled RFA is considered not medically necessary for SIJ.
- For SIJ RFA coverage, procedure must be conventional thermal lateral branch RFA per policy criteria.
Pulsed RFA is investigational and may be denied
Pulsed radiofrequency ablation remains investigational and not medically necessary for any indication; requests billed as PRF may be denied.
- PRF lacks standardized protocols and consistent durable benefit and therefore is excluded from coverage.
- If requesting PRF, consider individual case review with prior plan approval only in exceptional circumstances.
Individual case review with prior plan approval required for investigational treatments
Experimental, investigational, or unproven treatments may be denied unless an individual case review with prior plan approval is obtained; all such decisions are made by a Priority Health medical director or clinical pharmacist.
- Submit detailed clinical rationale and supporting evidence when requesting exception via individual case review.
- Exceptions require prior plan approval before services are rendered to be considered for coverage.
Cooled RFA (outside knee OA) classified investigational — denial risk
Cooled radiofrequency ablation is classified as investigational/uncertain for indications other than knee osteoarthritis; requests for cooled RFA outside the knee OA exception may be denied as investigational.
- Refer to Policy No. 91571 for the knee osteoarthritis exception.
- Document clinical rationale if requesting an exception; consider individual case review.
Denial risk if PA not obtained or criteria unmet for SIJ or repeat RFA
Failure to obtain required prior authorization or failure to meet the policy's medical necessity criteria for conventional SIJ RFA or repeat RFA may result in claim denial.
- Ensure PA includes diagnostic block results, provocation test findings, and documentation of conservative care.
- For repeat SIJ RFA, include documentation of prior pain relief (≥50%), and the required minimum intervals (≥12 weeks since prior ablation and ≥6 months since prior SI joint RFA where applicable).
Required Conservative Therapy Before Intervention
Documented trial and failure of conservative measures prior to procedure — minimum durations (6 months for basivertebral; 3 months for SI joint)
Documented trial and failure of conservative measures prior to procedure — minimum durations:
Documented failure of conservative therapies prior to neuroablation procedures as described — ≥6 months for Intracept; prior conservative management for SIJ RFA
Documented failure of conservative therapies prior to neuroablation procedures as described:
Procedure Frequency and Repeat Intervals
Imaging and Procedural Guidance Requirements
Lumbar MRI required for basivertebral nerve RFA
For basivertebral (Intracept) and other neuroablative procedures, include lumbar MRI to document Modic Type 1 or 2 endplate changes and imaging to exclude other structural causes when submitting authorization or chart documentation.
- MRI must show Modic Type 1 or Type 2 changes at treated levels for Intracept (L3–S1)
- Imaging to exclude tumors, infection, or other structural causes should be provided when relevant
Use fluoroscopy or CT for SIJ and Intracept procedures and diagnostic blocks
Procedure and diagnostic blocks for SIJ lateral branch RFA and Intracept BVN ablation should be performed under image guidance (fluoroscopy or CT); include imaging modality in procedural notes and PA documentation.
- State whether fluoroscopy or CT was used for diagnostic blocks and ablation
- For Intracept, document fluoroscopic cannula placement and target levels (L3–S1)
Perform facet, SIJ, and BVN RFA with fluoroscopy/CT when specified
When the policy specifies imaging guidance for facet, SIJ denervation, or intraosseous BVN RFA, perform the procedure with fluoroscopy or CT and document the imaging used in the operative/procedure note.
- Several CPT codes in the policy specify 'including imaging guidance' — reflect that in billing and documentation
Document imaging guidance and diagnostic block results for SIJ/facet procedures
Diagnostic blocks and subsequent RFA for SIJ and facet procedures are typically image-guided (fluoroscopy implied by policy references); record the imaging modality and the percent relief from each diagnostic block in the patient record.
- Report block technique, agents used, imaging guidance, and measured percent pain/function improvement
Excluded and Not Medically Necessary Procedures
As a summarized ‘‘not covered’’ statement, cooled RFA (except knee osteoarthritis per separate policy), pulsed RFA, and cryoneurolysis/cryoneuroablation are classified as not medically necessary/experimental or investigational for routine pain management indications. The policy directs providers to the separate knee OA policy for the single exception and indicates that requests for these investigational modalities may be denied absent an approved individual case review.
Intercostal nerve cryoablation and similar cryoanalgesia procedures are specifically called out among excluded techniques; routine use for post‑thoracotomy or other indications is considered experimental/investigational and therefore not covered under the policy.
This slot lists additional investigational or not-covered neuroablative procedures per the policy's exclusions; refer to the full policy exclusions for the complete set of non-covered techniques and indications.
This entry is reserved for other investigational or not-covered items as identified in policy updates and committee review; providers should consult the policy document for specifics.
Placeholder for further non-covered procedures; see policy exclusions and coding sections for up-to-date statements about investigational techniques.
Additional investigational or excluded procedures are enumerated in the policy's exclusions; clinicians should reference the policy for the definitive list.
Reserved for future policy-noted investigational or not covered procedures; current exclusions include cooled RFA (outside knee OA), pulsed RFA, and cryoneurolysis.
Definitions and Procedure Modalities
Policy Revision Summary
Removed the prior numeric limit of two RFA procedures per year and the associated requirement for medical review beyond two procedures.
Conventional sacroiliac joint radiofrequency ablation reclassified from investigational/uncertain to medically necessary when medical necessity criteria are met; prior authorization required.
Cooled radiofrequency ablation status updated: remains investigational/experimental/uncertain for all indications except knee osteoarthritis (see related knee OA policy No. 91571).
Added explicit medical necessity criteria for repeat radiofrequency ablation for back and neck pain.
Expanded not medically necessary/excluded list to explicitly include nerve cryoablation (e.g., intercostal nerve cryoablation) and cryodenervation; background and criteria language clarified.
Additional Notes and Placeholders
Background: Neuroablative techniques attempt to interrupt pain transmission using thermal or cold-based approaches. Conventional RFA produces thermal lesions (roughly 60–90°C) intended to denervate target nerves, while variants such as cooled RFA use internally cooled probes to create larger lesion volumes and pulsed RFA delivers intermittent lower-temperature bursts for neuromodulation. Cryoneurolysis applies extreme cold to induce reversible axonal injury with time-limited analgesia. The policy's coverage positions reflect variability in the evidence base across these modalities, particularly concerns about long-term durability, standardized technique, and patient selection.
Imaging guidance (fluoroscopy/CT) expected for diagnostic blocks and RFA
Fluoroscopy or CT is expected for image-guided diagnostic blocks and RFA procedures as referenced across SIJ, facet, and intraosseous BVN sections; ensure procedural notes explicitly document the guidance modality.
- Include fluoroscopic images or CT confirmation in the chart when available
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