ModifiedUnitedHealthcarePolicy CS001KY.10

Ablative Treatment for Spinal Pain (for Kentucky Only)

Medical policy for ablative treatments for spinal pain applicable to Kentucky providers and members; describes coverage rationale, specific techniques considered unproven, coding references, and evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Kentucky Only)

Policy CodePolicy CS001KY.10

Change TypeUpdated clinical evidence and references

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization using InterQual CP: Procedures, Neuroablation, Percutaneous and document Modic type 1 or 2 changes, ≥6 months of symptoms, prior conservative therapy, and baseline ODI/pain scores.

SourceLink

POLICY UPDATE CHANGES

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

78%BVNA 5-year follow-up completion

32.1%Participants pain free at 5 years

4.32-pointMean NPS improvement at 5 years

5.6 yearsMean follow-up (pooled)

Several

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Techniques evaluated

2026-03-01Policy revision date

Coverage Criteria for Ablative Treatments

Medical necessity (interQual referenced)

Covered when meeting external InterQual criteria

InterQual-based medical necessity: Ablative treatment is medically necessary in certain circumstances when the InterQual CP: Procedures, Neuroablation, Percutaneous clinical coverage criteria are met.

Refer to InterQual for detailed clinical entry/exit criteria and conservative therapy requirements.

Unproven / Not Medically Necessary Procedures

Not medically necessary / unproven procedures

Unproven techniques: 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; Cooled Radiofrequency Ablation; Laser ablation (including pulsed, continuous, or low level); Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) for the treatment of spinal pain.

These are considered unproven and not medically necessary due to insufficient evidence of efficacy.

Initial treatment (trial-derived eligibility)

Covered when ALL of the following are met (criteria derived from clinical trials summarized in this document):

Imaging criteria: Modic type 1 or 2 vertebral endplate changes at levels L3 to S1Modic type 1 or 2 at L3-S1

required enrollment criterion in the randomized trials (Intracept, SMART)

Failure of conservative care: Documented failure or inadequate response to conservative therapies prior to BVNAas documented in clinical record

Trials enrolled patients refractory to nonsurgical care; conservative therapy expected per guidance and InterQual

Baseline outcome measures documented: Baseline ODI and pain (VAS/NPS) recordedODI and NPS/VAS values documented

Observed long-term outcomes

Continuation / expected outcomes logic (evidence-based performance expectations):

Expected benefit: Significant mean improvements in ODI and pain scores observed at 3 years and 5 years in pooled analysesODI reductions ~28-31 points; NPS reductions ~4.3 points

Pooled analyses (3- and 5-year) demonstrate durable functional and pain improvements

Opioid and intervention reduction: Substantial reductions in opioid use and spinal injections following BVNAopioid reductions up to ~65% at 5 years; therapeutic spinal interventions reduced by >50% at 3 years

Observed in pooled long-term follow-up studies with low rates of serious device-related adverse events

The policy states that several facet joint nerve ablation techniques are considered unproven and not medically necessary due to insufficient evidence of efficacy. These include endoscopic radiofrequency ablation/endoscopic rhizotomy, pulsed radiofrequency ablation of the facet nerves, sacral nerve root, or dorsal root ganglion, cooled radiofrequency ablation, and laser ablation. In addition, intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept®) for spinal pain is listed as unproven and not medically necessary on the same basis.

The policy explains that limitations in the available evidence justify the unproven stance: published assessments (for example, Hayes and ECRI) identify small or low-quality studies, manufacturer-sponsored trials, inconsistent results versus sham controls, and a need for larger, multicenter, blinded randomized trials. The Hayes review and updated evidence summaries note that while individual studies report improvements in pain and function, concerns about study design, placebo response, and high risk of bias mean the current evidence is insufficient to establish routine coverage.

The document clarifies that FDA approval or device listing alone is not a basis for coverage. Although the FDA regulates RFA devices and lists product codes (for example, GXD, GXI, GEI), the policy uses clinical evidence and established coverage criteria—not regulatory clearance—to determine medical necessity.

Specifically named techniques the policy identifies as unproven and not medically necessary are: endoscopic radiofrequency ablation/endoscopic rhizotomy; pulsed radiofrequency ablation of the cervical, thoracic, or lumbar facet nerves, the sacral nerve root, or the dorsal root ganglion; cooled radiofrequency ablation; and laser ablation. The policy also lists intraosseous radiofrequency ablation of the basivertebral nerve (Intracept®) as unproven and not medically necessary.

The policy indicates examples of situations where routine coverage is not supported by the evidence: use of basivertebral nerve ablation without documented Modic type 1 or 2 vertebral endplate changes on MRI, and offering these procedures without a documented trial of prior conservative therapies. Reviews cited in the policy also emphasize that outcomes reported in some unblinded or non-sham-controlled trials should be interpreted cautiously and are insufficient to justify routine coverage when these selection and conservative-care requirements are not met.

Coding and Billing References

Applicable/Referenced Procedure CodesCPT

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).
64625	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography).
64999	Unlisted procedure, nervous system (may be used to report pulsed radiofrequency ablation).
22899	Unlisted procedure, spine (when used to report the Intracept procedure or cooled radiofrequency ablation).
27299	Unlisted procedure, pelvis or hip joint.

FDA Product Codes Referencedmixed

GXD	Radiofrequency lesion generators (FDA product code).
GXI	Radiofrequency lesion probes (FDA product code).
GEI	Electrosurgical cutting and coagulating device and accessories (FDA product code).

Covered/Related Codes (Informational)CPT

64628	Thermal destruction of intraosseous basivertebral nerve; primary procedure code referenced in evidence summaries.
64629	Each additional vertebral body; add-on code referenced in evidence summaries.
64999	Unlisted procedure, nervous system — may be used when no specific CPT exists for procedure variant (e.g., pulsed RFA).
22899	Unlisted procedure, spine — sometimes used to report Intracept procedure or cooled RFA.

Key Study Thresholds and Symptom Duration

Minimum duration of symptoms≥ 6 months of chronic low back pain (as used in key clinical trials).

Responder thresholds used in studiesCommon responder definitions included ≥10-point improvement in ODI and ≥50% reduction in pain (NPS/VAS) from baseline; some analyses used ≥15-point ODI improvement as an MCID.

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required and is tied to the InterQual® Procedures: Neuroablation, Percutaneous criteria for medical necessity determinations. Providers must verify that the requested procedure meets the applicable InterQual criteria before authorization is requested.

Check and apply the current InterQual® criteria when submitting prior authorization requests
Authorization determinations may require submission of the InterQual® supporting documentation and clinical data

Denial Risk

Denial Risk for Unproven Procedures

Certain procedures and techniques are considered unproven and carry a high risk of coverage denial due to insufficient evidence of efficacy. Requests for these procedures should be expected to be denied unless compelling, plan-specific exceptions are documented.

Endoscopic radiofrequency ablation/endoscopic rhizotomy

Conservative Care Preconditions

Imaging and Procedural Guidance

Billing Rule

Image guidance is typically required for CPTs 64625, 64628, 64629 — document it

When performing CPT-coded procedures 64625, 64628, or 64629, image guidance is typically required per the procedure descriptors; ensure image guidance is performed and documented as part of the procedure record.

CPT 64625 descriptor references fluoroscopy or CT image guidance.
CPT 64628/64629 include all imaging guidance in the descriptor for intraosseous BVN thermal destruction.

Documentation Required

BVNA requires MRI documentation of Modic type 1 or 2 changes for selection/authorization

BVNA authorization and patient selection rely on MRI demonstrating Modic type 1 or 2 vertebral endplate changes at treated levels; include the MRI findings in the documentation for medical necessity.

Repeat Procedures and Frequency Guidance

inv-35: RFA procedures generally (guideline context) — frequency/repeat suggestions

Suggested repeat interval (facet RFA)Typically ≥ 6 months between procedures for the same region (maximum ~2 times per year) if ≥50% relief is obtained for 5–6 months

Regional timing when treating different regionsIf treating different regions, procedures may be performed no sooner than 1 week (preferably 2 weeks) apart if not done in one setting

Repeat only as medically necessaryTherapeutic procedures should be repeated only as necessary according to medical necessity criteria and guideline recommendations

Definitions and Terminology

inv-28: Cooled Radiofrequency Ablation definition

DefinitionCooled Radiofrequency Ablation: application of continuous high-frequency electrical current to ablate nerve tissue using water-cooled electrodes/probes

Technique featureUses water-cooled probes to maintain electrode temperature during continuous RF energy delivery

Coverage stanceListed among techniques considered unproven/not medically necessary in this policy

inv-29: Pulsed Radiofrequency Ablation definition

DefinitionPulsed Radiofrequency Ablation: delivers intermittent short bursts of energy (not continuous) using a probe temperature of 42°–45° C

Energy deliveryIntermittent pulses of RF energy rather than continuous thermal lesioning

Background on Ablative Therapies

Ablative techniques encompass a range of methods that intentionally disrupt or destroy pain-transmitting nerve tissue to treat spinal pain. The policy references continuous thermal techniques (thermal radiofrequency ablation), pulsed and cooled radiofrequency approaches, endoscopic rhizotomy techniques, intraosseous basivertebral nerve ablation (BVNA/Intracept®), laser ablation, cryoablation, and chemical ablation. It notes that while some procedures have published trial data, the strength and quality of evidence vary substantially across techniques and that higher-quality randomized, blinded, and comparative trials are needed to establish long-term clinical benefit and appropriate patient selection.

Services Not Covered / Considered Experimental

The policy lists procedures considered not covered or experimental, including endoscopic radiofrequency ablation/endoscopic rhizotomy; pulsed radiofrequency ablation of the facet nerves, sacral nerve root, or dorsal root ganglion; cooled radiofrequency ablation; laser ablation (pulsed, continuous, or low-level); and intraosseous radiofrequency ablation of the basivertebral nerve (Intracept®). The policy explains these are designated as not medically necessary because of insufficient and inconsistent evidence of efficacy.

Policy Revision History

2026-03-01policy_revisionLatest

Updated Clinical Evidence and References sections; archived prior policy version CS001KY.09.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Kentucky Only)

Policy CodePolicy CS001KY.10

Change TypeUpdated clinical evidence and references

Effective DateMar 1, 2026

Next Review DateN/A

SourceLink

On This Page

Used in trials to assess treatment effect and for prior authorization documentation

Pulsed radiofrequency ablation of facet nerves, sacral nerve root, or dorsal root ganglion

Cooled radiofrequency ablation

Laser ablation (pulsed, continuous, low-level)

Intraosseous RFA of the basivertebral nerve (Intracept®) — considered unproven by this policy

Denial Risk

Evidence Limitations That May Trigger Coverage Denial

Clinical evidence limitations for a given procedure (small or poor-quality studies, manufacturer-sponsored trials with bias, lack of convincing sham-controlled benefit, inconsistent guideline support) may trigger coverage denial. When the evidence base is minimal or conflicting, coverage is typically not supported.

RCTs with high crossover or limited follow-up that do not show clear benefit versus sham may lead to noncoverage
Manufacturer-sponsored studies with design limitations or poor-quality methodology reduce likelihood of coverage
Absence of systematic reviews or guideline endorsement for a technique may prompt denial

Note

Contractual/State/Federal Requirements Govern

Federal, state, and contractual plan terms govern benefit determinations and may differ from this standard policy. In the event of a conflict, the applicable federal, state, or contractual requirements take precedence. Providers should confirm plan-specific benefit language and regulatory requirements before proceeding.

Verify federal/state/contractual plan requirements prior to authorization submission
This policy is informational and may be superseded by jurisdictional or contract-specific mandates

Documentation Required

Coding and Documentation Notes

Accurate coding and complete documentation are required to support medical necessity and authorization. Use the most specific CPT/HCPCS/ICD-10 codes and include operative, imaging, and diagnostic code cross-references where applicable.

Report CPT 64999 for pulsed radiofrequency ablation when applicable (per CPT® Assistant guidance)
Use unlisted spine/pelvis codes (e.g., 22899, 27299) only when appropriate and include full operative report and device documentation
Report 64628/64629 for intraosseous basivertebral nerve thermal destruction when applicable; otherwise include rationale for use of unlisted codes

Documentation Required

Suggested Clinical Documentation to Support Medical Necessity

Provide focused clinical documentation to demonstrate medical necessity and to align with InterQual criteria and guideline-based expectations. Include prior conservative care, diagnostic block responses, imaging findings, and symptom severity/duration.

History and physical with pain localization and duration (≥ 6 months when applicable)
Results of diagnostic medial branch blocks or dual diagnostic blocks and documented positive response when required
Imaging reports (e.g., Modic type 1 or 2 changes between L3–S1 for BVN procedures) with dates
Previous conservative treatments tried and failed (e.g., medications, physical therapy, injections) and duration of each
Operative report and device-specific documentation for procedures using novel devices

Note

Check Plan-Specific Requirements

Check plan-specific requirements and member benefit language before submitting an authorization request. Coverage, prior authorization processes, and required documentation may vary by contract, state Medicaid requirements, and employer group plan.

Confirm member eligibility and benefit coverage for the requested service
Review plan-specific prior authorization portals and required forms
For Medicaid or state-regulated plans, follow any state-mandated coverage rules or documentation requirements

Step Therapy

Step/Conservative Therapy Reference

Prior to considering ablative procedures, document that appropriate step/conservative therapies have been attempted and failed per guideline recommendations. Many guidelines require trials of nonoperative care and positive diagnostic blocks before proceeding to ablation.

Conservative care examples: active physical therapy, supervised exercise, pharmacologic management, appropriate injections
Document duration and response to conservative therapies (e.g., at least several weeks to months depending on guideline and condition)
Ensure diagnostic selection aligns with guideline recommendations (e.g., positive diagnostic medial branch block before RFA)

Step Therapy

Conservative Care and Diagnostic Selection

Select and document diagnostic tests and conservative treatments that align with guideline-recommended pathways and InterQual requirements. Diagnostic blocks, imaging to identify Modic changes, and documented pain severity are commonly required elements.

Diagnostic medial branch blocks or dual blocks with documented positive response when indicated
Imaging demonstrating anatomy consistent with the proposed target (e.g., Modic type 1 or 2 changes for BVN targeting)
Documentation of prior conservative care modalities and outcomes

Trials required Modic type 1 or 2 changes between L3 and S1 for enrollment.
Include MRI report describing Modic type and levels when requesting authorization.

Note

Device/registry info provided; no additional imaging requirement stated in device section for RFA/spinal ablation

The device and regulatory discussion notes FDA product codes for RFA devices (GXD, GXI, GEI) but this section does not specify an additional imaging requirement for radiofrequency or spinal ablation therapies beyond procedure descriptors.

FDA product codes are informational only; FDA approval alone is not a basis for coverage.
No separate imaging mandate is specified in the device/regulatory section for general RFA therapies.

Coverage stancePulsed RFA of facet nerves, sacral nerve root, or dorsal root ganglion is considered unproven/not medically necessary in this policy

inv-30: Vertebrogenic CLBP — description and Modic association

DescriptionVertebrogenic chronic low back pain: CLBP thought to originate from vertebral endplates, typically associated with Modic type 1 or 2 changes

Imaging associationTrials required Modic type 1 or 2 vertebral endplate changes between L3 and S1 for enrollment

Patient selection implicationPresence of Modic 1/2 on MRI is a key selection criterion for BVNA (Intracept/SMART) trials

inv-31: Intracept/BVNA definition

DefinitionIntracept/BVNA: percutaneous intraosseous radiofrequency ablation of the basivertebral nerve using devices such as the Intracept system

Procedure contextUsed to treat vertebrogenic CLBP in patients with Modic type 1 or 2 changes; evaluated in randomized and pooled trials

Coding noteCPT descriptors and trial reports reference specific intraosseous BVN ablation procedures (e.g., CPT 64628/64629 listed elsewhere in policy)

inv-32: RFA devices product codes (GXD, GXI, GEI)

Radiofrequency lesion generatorsFDA product code GXD

Radiofrequency lesion probesFDA product code GXI

Electrosurgical cutting/coagulating device accessoriesFDA product code GEI