CurrentUnitedHealthcarePolicy PAIN 021.24

Ablative Treatment for Spinal Pain

Defines UnitedHealthcare's coverage rationale, definitions, applicable CPT/unspecified procedure codes, and clinical evidence summaries for various ablative treatments for spinal pain including conventional (thermal) RFA, pulsed RFA, endoscopic rhizotomy, cryoablation, cooled RFA, chemical ablation, laser ablation, and intraosseous basivertebral nerve ablation (Intracept). This part lists techniques considered unproven/not medically necessary and summarizes clinical evidence and guideline recommendations.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain

Policy CodePolicy PAIN 021.24

Change TypeSupporting information update

Effective DateFeb 1, 2025

Next Review Date

Key ActionDocument positive response to diagnostic medial branch block before performing RFA and record prior magnitude and duration of pain relief to justify repeat RFA per policy frequency limits.

SourceLink

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence and References sections to reflect the most current information.

7Ablation techniques listed as unproven/not medically necessary

3Specific CPT codes referenced for basivertebral nerve procedures

MultipleGuideline sources summarized

>=50%Common clinical benefit threshold for repeat procedures

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Coverage Summary

Scope: This policy (PAIN 021.24, effective 2025-02-01) addresses UnitedHealthcare's coverage rationale for ablative treatments for spinal pain including: conventional (thermal) radiofrequency ablation (RFA), cooled RFA, pulsed RFA, endoscopic rhizotomy (endoscopic RFA), cryoablation, chemical ablation, laser ablation, and intraosseous basivertebral nerve ablation (BVNA/Intracept).

Coverage stance overview: The policy takes a mixed coverage stance — supporting established uses of thermal RFA in accordance with guideline recommendations while identifying several ablative modalities as unproven and not medically necessary because of insufficient or low-quality evidence. The policy number is PAIN 021.24 and the effective date is 2025-02-01.

Unproven / Not medically necessary techniques (listed by the policy): endoscopic radiofrequency ablation / endoscopic rhizotomy; pulsed radiofrequency ablation of facet nerves, sacral nerve root, or dorsal root ganglion; cryoablation (cryodenervation/cryoneurolysis/cryosurgery/cryoanesthesia); chemical ablation (e.g., alcohol, phenol, sodium morrhuate); cooled radiofrequency ablation; and laser ablation (pulsed, continuous, or low level).

Key thresholds & quick facts

Policy numberPAIN 021.24

Effective dateFebruary 1, 2025

Coverage stanceMixed — several ablative techniques listed as unproven/not medically necessary; intraosseous BVNA described as unproven/not medically necessary despite some positive trials

Pain referral threshold for consideration (NICE)>= 5 on VAS

Clinical benefit threshold for repeat RFA>= 50% pain relief at 3 months (or >=50% relief for 5-6 months per ASIPP)

Maximum frequency of repeat proceduresNo more than 2 procedures per year

Number of techniques listed as unproven/not medically necessary7

Number of CPT codes referenced for BVNA3

Medical-Necessity and Not Medically Necessary Criteria

Not Medically Necessary / Unproven Ablation Techniques

The following facet joint nerve ablation techniques are unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Endoscopic radiofrequency ablation / endoscopic rhizotomy
Pulsed Radiofrequency Ablation of the facet nerves of the cervical, thoracic, or lumbar region, sacral nerve root, or dorsal root ganglion
Cryoablation (cryodenervation, cryoneurolysis, cryosurgery, or cryoanesthesia)
Chemical ablation (including but not limited to alcohol, phenol, or sodium morrhuate)

Coding

Unlisted / Reporting codes referencedCPT

22899	Unlisted procedure, spine [when used to report the Intracept procedure or cooled radiofrequency ablation]
27299	Unlisted procedure, pelvis or hip joint
64999	Unlisted procedure, nervous system

Specific ablative procedure codes referencedCPT

64625	Radiofrequency ablation, nerves innervating the sacroiliac joint; with image guidance (i.e. fluoroscopy or computed tomography)
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 (List separately in addition to code for primary procedure)

Regulatory / Device product codes (informational)mixed

GXD	FDA product code - radiofrequency lesion generators
GXI	FDA product code - radiofrequency lesion probes
GEI	FDA product code - electrosurgical cutting and coagulating devices and accessories

Provider Actions and Documentation Requirements

Documentation Required

Site of service review for Conventional (Thermal) RFA

Site of service review is required for Conventional (Thermal) Radiofrequency Ablation. Refer to the Clinical Policy titled “Office-Based Procedures: Site of Service” for applicable site-of-service determination and review requirements.

Documentation Required

Use of diagnostic medial branch blocks

Document a positive response to diagnostic medial branch block(s) prior to performing radiofrequency ablation. For sacroiliac joint (SIJ) procedures using cooled RFA, dual diagnostic blocks are recommended per specialty guidance.

Documentation Required

Record prior benefit for repeat procedures

Document prior clinical benefit from the earlier RFA procedure — including the magnitude and duration of pain relief — to support medical necessity for repeat RFA and to confirm adherence to procedural frequency limits. Typical thresholds cited by guidelines include at least 50% pain relief at 3 months or sustained relief for 5–6 months; repeat procedures generally limited to no more than two per year.

Background and Evidence Summary

Background: The policy defines and reviews multiple ablative modalities for spinal pain: conventional/thermal RFA, cooled RFA, pulsed RFA, endoscopic rhizotomy (endoscopic RFA), cryoablation, chemical ablation, laser ablation, and intraosseous basivertebral nerve ablation (BVNA/Intracept).

Evidence summary: For many of these modalities the policy concludes there is insufficient evidence to establish safety and efficacy. The clinical literature includes systematic reviews, randomized trials, prospective cohorts, and case series but is frequently limited by small sample sizes, short follow-up, methodological limitations, industry sponsorship, inconsistent techniques, and risk of bias.

Technology assessments and guideline sources cited: the policy references major technology assessments and evidence reviews such as AHRQ (Chou et al.), Hayes health technology assessments and evidence briefs, and an ECRI assessment of Intracept; and it summarizes clinical practice guideline recommendations from specialty societies including ASIPP and ASRA (and also cites NASS and NICE in guideline discussion).

Source	Summary
Hayes health technology assessment (2022/2023/2024 summaries)
Reviewed cooled RFA and Intracept; concluded evidence limited with some positive trials but overall insufficient — calls for larger, high-quality trials and cautious interpretation of open-label findings.
SMART trial (Fischgrund et al., 2018)
Randomized, double-blind, sham-controlled trial of Intracept showed improvements in ODI and pain versus sham at 3 months but differences were small; high crossover and limited longer-term controlled comparisons.
McCormick et al. (2019)
Randomized trial comparing cooled RFA versus traditional RFA for lumbar medial branch nerves found higher responder rates with C-RFA at 6 months but differences were not statistically significant; study inconclusive due to small sample size.
Cohen et al. (2023)
Multicenter randomized comparative effectiveness trial showed CRFA superior to standard medical management for chronic SIJ pain at 3 months across pain, function, and QoL measures but limited by short follow-up and heterogeneous control treatments.
ASIPP evidence level
ASIPP: Level II evidence (moderate strength) for cervical and lumbar RFA; Level III (weak–moderate) for thoracic RFA; recommends repeat procedures only with demonstrated benefit and suggests intervals of ≥6 months (max 2/year) when ≥50% relief obtained for 5–6 months.
Cohen et al. recommendation
Consensus guideline: recommend repeat RFA for recurrence in patients who had benefit from first RFA, typically defined as ≥50% pain relief at 3 months; limit repeats to no more than two times per year.

Definitions

Conventional (Thermal) Radiofrequency Ablation: Application of continuous high-frequency electrical current to ablate nerve tissue with ablation durations typically 2–40 seconds and confirmation of needle placement by fluoroscopic guidance.

Cooled Radiofrequency Ablation: Application of continuous high-frequency electrical current using water-cooled electrodes/probes to create larger lesions for denervation.

Pulsed Radiofrequency Ablation: A technique that delivers intermittent short bursts of energy rather than continuous thermal energy.

RFA (general): Radiofrequency ablation/denervation procedures targeting medial branch nerves, lateral branch nerves, the basivertebral nerve, or dorsal root ganglion depending on the clinical indication.

Medial branch block: A diagnostic injection used as a prognostic screening test prior to facet RFA (recommended by ASRA and noted as required by NICE prior to radiofrequency denervation).

Revision History

2025-02-01revisedLatest

Archived previous policy version PAIN 021.23; Supporting Information Updated Clinical Evidence and References sections to reflect the most current information.

Guideline-based recommendations (summarized)

Summarized recommendations from specialty society guidelines and NICE:

ALL of the following

ASIPP cervical/lumbar RFA: ASIPP: Moderate strength recommendation (Level II evidence) for cervical and lumbar RFA.
ASIPP thoracic RFA: ASIPP: Weak to moderate recommendation (Level III evidence) with emerging evidence for thoracic RFA.
ASIPP frequency suggestion: ASIPP: For facet joint nerve ablation, suggested frequency is 6 months or longer, maximum of 2 times per year, provided ≥50% relief is obtained for 5-6 months.
ASIPP medial branch interval: ASIPP: Medial branch neurotomy therapeutic frequency should be at intervals of at least 6 months per region; treat multiple regions at the same time when safe.
ASRA recommendation: ASRA: Medial branch blocks should be the prognostic screening test of choice before lumbar facet RFA.
Cohen et al. repeat criteria: Cohen et al.: Repeat RFA for recurrence is recommended for patients who had benefit from first RFA, typically defined as ≥50% pain relief at 3 months; repeat procedures no more than twice per year.
NICE referral criteria: NICE: Consider referral for RFA for chronic low back pain when non-surgical treatment has not worked; pain rated ≥5/10 on VAS; main source thought to be from medial branch–supplied structures; only after positive response to diagnostic medial branch block; imaging not required as prerequisite.
NASS recommendations: NASS: Thermal RFA suggested for LBP from zygapophyseal joints; relief durable for at least 6 months; recommend more stringent diagnostic criteria. NASS: Cooled RFA of sacral lateral branch and dorsal ramus may be considered for SIJ pain diagnosed with dual diagnostic blocks (Grade C). NASS: Insufficient evidence to recommend for or against cryodenervation for zygapophyseal joint pain.