CurrentUnitedHealthcarePolicy CSNCT0107.06

Ablative Treatment for Spinal Pain (for North Carolina Only) – Community Plan Medical Policy

UnitedHealthcare Community Plan medical policy for North Carolina that addresses coverage rationale, definitions, evidence review, guidelines, and applicable procedure/diagnosis codes for various ablative treatments for spinal pain (part 1 of 2).

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for North Carolina Only) – Community Plan Medical Policy

Policy CodePolicy CSNCT0107.06

Change TypeCoding/coverage caveatevidence updatearchival

Effective DateApril 1, 2026

Next Review Date

Key ActionWhen billing for codes 22899, 27299, 64625, 64628, 64629, or 64999, note these CPT codes are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

SourceLink

POLICY UPDATE CHANGES

Coding/coverage caveat specific to NC Medicaid effective 04/01/2026.

Evidence and references updated (Hayes reviews and multiple clinical studies cited); archived prior policy CSNCT0107.05.

Administrative archival of prior version.

6Unproven/not medically necessary techniques listed

3Device/procedure categories summarized

6CPT codes with NC caveat

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Coverage Summary

UnitedHealthcare Community Plan medical policy for North Carolina: Ablative Treatment for Spinal Pain (Policy Number CSNCT0107.06). Part 1 of 2 summarizing coverage determinations that multiple ablative techniques for spinal pain are considered unproven / not medically necessary due to insufficient evidence of efficacy. Includes an NC-specific coding caveat. Effective date: 2026-04-01.

Key statistics

Ablation techniques listed as unproven/not medically necessary in this part6

Device/procedure categories discussed with evidence summaries3

CPT codes with NC caveat6

Medical-Necessity and Not Medically Necessary Criteria

Coding

Applicable / referenced CPT and unlisted procedure codes (reference only)CPT

22899	Unlisted procedure, spine [when used to report the Intracept procedure or cooled radiofrequency ablation]
27299	Unlisted procedure, pelvis or hip joint
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)
64999	Unlisted procedure, nervous system
64999	CPT code to be used for Pulsed Radiofrequency Ablation (per CPT Assistant, 2016) - coding clarification in policy

Codes not on NC Medicaid Fee Schedule (may not be covered by NC Medicaid)CPTNot Covered

22899	Unlisted procedure, spine
27299	Unlisted procedure, pelvis or hip joint
64625	Radiofrequency ablation, nerves innervating the sacroiliac joint
64628	Thermal destruction of intraosseous basivertebral nerve; first 2 vertebral bodies
64629	Thermal destruction of intraosseous basivertebral nerve; each additional vertebral body
64999	Unlisted procedure, nervous system

Indication CPT codes with NC Medicaid fee-schedule caveatCPT

22899	Unlisted procedure, spine
27299	Unlisted procedure, pelvis/hip region
64625	Destruction by neurolytic agent; other peripheral nerve (e.g., greater occipital, lateral femoral cutaneous)
64628	Destruction by neurolytic agent; other peripheral nerve (continuous or pulsed radiofrequency)
64629	Destruction by neurolytic agent; other peripheral nerve (adjacent to dorsal root ganglion)
64999	Unlisted procedure, nervous system

Billing Rule

NC Medicaid fee-schedule caveat for certain CPT codes

When billing for any of these procedure codes, note they are not listed on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program (changes effective 04/01/2026).

22899
27299
64625
64628
64629
64999

Documentation Required

Coding clarification for pulsed RFA

CPT code 64999 is the coding designation to be used for Pulsed Radiofrequency Ablation per CPT Assistant (2016); document use of this unlisted nervous system code accordingly in the record.

Provider Actions & Documentation Requirements

Documentation Required

Evidence and references must be available

Providers should document the indication and clinical rationale consistent with the policy's supporting information and clinical evidence sections. Evidence and references were updated as of 04/01/2026 and should be available to support clinical decisions.

Billing implications and recommended workflow: check the State of North Carolina Medicaid Fee Schedule to confirm whether CPT codes listed in this policy (including codes noted with an asterisk) are covered by NC Medicaid. When submitting claims, document the clinical indication, rationale, and supporting evidence consistent with the policy’s supporting information and clinical evidence sections; note that CPT code 64999 is the CPT Assistant–recommended code for pulsed radiofrequency ablation and that certain codes (22899, 27299, 64625, 64628, 64629, 64999) are not on the NC Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Background and Evidence Summary

Background: This Medical Policy applies only to North Carolina and summarizes the evidence, guideline recommendations, and coding considerations for multiple ablative modalities for spinal pain. The policy reviews pulsed RFA, endoscopic RFA/endoscopic rhizotomy, cryoablation, cooled RFA, laser ablation, sacroiliac joint ablation, and intraosseous basivertebral nerve ablation, and concludes in part 1 that several techniques are unproven / not medically necessary due to insufficient evidence. The policy also notes coding and fee-schedule considerations for specific CPT and unlisted procedure codes. The prior policy version CSNCT0107.05 was archived as part of the April 1, 2026 updates.

Source	Key takeaway
AHRQ comparative effectiveness review (Chou et al., 2021)	Concluded evidence insufficient to assess pulsed RFA versus sham or continuous RFA for facet joint pain (insufficient evidence of efficacy).
Hayes assessments	Multiple Hayes HTA reports generally conclude low or insufficient-quality evidence for pulsed RFA, cooled RFA (CRFA), and Intracept (BVN RFA) across various indications; updates through 2024/2025 noted.
SMART trial (Fischgrund et al., 2018)	Randomized double-blind sham-controlled RCT of BVN RFA showed improvement versus sham but the between-group difference was considered small; limitations include crossover and short safety data collection.
Hayes Evidence Reviews	Specific Hayes evidence reviews cited: PRF to dorsal root ganglion (2019, updated 2021) and Intracept intraosseous nerve ablation (2021, updated June 2024), concluding limited or minimal support and need for higher-quality studies.
Randomized trials (e.g., INTRACEPT, Khalil et al. 2019; Smuck et al. 2021)	INTRACEPT trial(s) reported improvements in ODI and pain versus standard care or baseline, but limitations include lack of blinding in some trials and risk of bias; evidence quality considered low to moderate and further blinded RCTs needed.
Guidelines (NICE NG59, ASIPP 2020, ACP 2017, NASS 2020)	Guidelines provide conditional recommendations: consider RFA after positive diagnostic blocks (NICE), ASIPP supports cervical/lumbar RFA (moderate strength), NASS suggests thermal RFA for zygapophyseal joint pain but finds insufficient evidence for cryodenervation; overall guidance varies and emphasizes diagnostic blocks and selective use.

Definitions

Cooled Radiofrequency AblationThe application of continuous high frequency electrical current to ablate nerve tissue using water-cooled electrodes/probes.

Pulsed Radiofrequency AblationTechnique that delivers intermittent short bursts of energy, instead of continuous energy, using a probe temperature of 42° to 45° C (Hayes, 2023).

Revision History

2026-04-01material_changeLatest

Added notation that CPT codes 22899, 27299, 64625, 64628, 64629, and 64999 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program (coding/coverage caveat specific to NC Medicaid).

2026-04-01revisedLatest

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