CurrentUnitedHealthcarePolicy CSOOIOH.C

Ablative Treatment for Spinal Pain (for Ohio Only)

State-specific UnitedHealthcare medical policy (Ohio) governing use and coverage rationale for various ablative treatments for spinal pain, listing techniques considered unproven/not medically necessary, definitions, evidence summary, guidance references, and applicable procedure codes. Applies only to Ohio and references InterQual CP: Procedures, Neuroablation, Percutaneous for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Ohio Only)

Policy CodePolicy CSOOIOH.C

Change TypeRevision (05/01/2025) - material and non-material updates

Effective DateMay 1, 2025

Next Review Date

Key ActionConfirm patient is an Ohio member; evaluate services stated as unproven or with coverage/quantity limits under Ohio Administrative Code 5160-1-01 and InterQual CP: Procedures, Neuroablation, Percutaneous.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale: Removed language indicating ablation for treating sacroiliac pain is unproven and not medically necessary due to insufficient evidence of efficacy.

Definition: Removed definition of 'Conventional (Thermal) Radiofrequency Ablation'.

Archived previous policy version CSOO1OHB.

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

1State-specific policy (Ohio)

5Techniques listed as unproven

6Procedure codes referenced

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multipleReferences cited

Coverage Summary

This is the Ohio-specific UnitedHealthcare coverage criteria for ablative treatment for spinal pain (state-only applicability). The policy takes a mixed coverage stance: certain ablative treatments are medically necessary in defined circumstances while several techniques are listed as unproven / not medically necessary due to insufficient evidence. For specific medical necessity determinations, refer to InterQual CP: Procedures, Neuroablation, Percutaneous. Effective date: 2025-05-01.

Key policy facts

Policy numberCSOOIOH.C

SubjectAblative treatment for spinal pain (Ohio only)

ScopeState-specific UnitedHealthcare medical policy (Ohio) governing use and coverage rationale for various ablative treatments for spinal pain; refers to InterQual CP: Procedures, Neuroablation, Percutaneous for medical necessity

Effective date2025-05-01

StatusCURRENT

Techniques listed as unproven5

Procedure codes referenced6

Material policy changes in latest revision1 (removed language re: SIJ ablation unproven; removed definition of Conventional RFA)

Medical Necessity and Coverage Criteria

General Coverage Rationale

Ablative treatment medical necessity decisions and where to find the detailed clinical criteria.

Jurisdictional rule: Requests for services stated as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01.

operational jurisdictional rule

Clinical criteria reference: For specific medical necessity clinical coverage criteria refer to InterQual CP: Procedures, Neuroablation, Percutaneous.

external criteria source

FDA/device note: RFA is a procedure not regulated by FDA; FDA regulates devices used for RFA (product codes GXD, GXI, GEI).

informational

Unproven / Not Medically Necessary Ablative Techniques

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

Cooled Radiofrequency Ablation

listed as unproven for facet joint nerve ablation

Endoscopic radiofrequency ablation / Endoscopic rhizotomy

listed as unproven for facet joint nerve ablation

Laser ablation (including pulsed, continuous, or low level)

listed as unproven for facet joint nerve ablation

Pulsed Radiofrequency Ablation of the facet nerves of the cervical, thoracic, or lumbar region, sacral nerve root, or dorsal root ganglion

listed as unproven for facet joint nerve ablation

Procedure / Device Codes Referenced

Unlisted / Applicable procedure codes (reference only)CPT|HCPCS|mixed

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
64999	Unlisted procedure, nervous system

FDA device 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)

Payers note guidance for reporting unlisted procedures: use CPT 64999 for pulsed radiofrequency per CPT Assistant (2016) and 22899 may be used to report the Intracept procedure or cooled RFA; follow payer-specific instructions and provide documentation to support medical necessity.

Provider Actions and Billing Guidance

Documentation Required

State-specific applicability and medical necessity evaluation

Confirm member is an Ohio member. Services stated as unproven or with coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-1-01 and InterQual CP: Procedures, Neuroablation, Percutaneous criteria. Refer to InterQual for specific medical necessity clinical coverage criteria.

Billing Rule

Use of unlisted codes for certain procedures

Use unlisted procedure codes per coding guidance when reporting certain ablative procedures. For pulsed radiofrequency ablation, report CPT 64999 per CPT Assistant (2016). Use 22899 to report the Intracept procedure or cooled radiofrequency ablation when applicable. Follow payer guidance for unlisted procedure reporting and provide documentation to support medical necessity.

64999

Background and Evidence Summary

This policy reviews multiple ablative modalities (pulsed RFA, endoscopic rhizotomy, cryoablation, cooled RFA, chemical ablation, laser ablation, and intraosseous basivertebral nerve RFA), summarizes the clinical evidence and guideline recommendations, and includes FDA device/product code information. It highlights that many techniques lack sufficient high-quality evidence to establish safety and efficacy and therefore are considered unproven or require InterQual criteria for medical necessity.

Study / Source	Key points
SMART trial (Fischgrund et al. 2018)
225 randomized (Intracept vs sham); clinically meaningful ODI improvements with treatment but only a small difference versus sham at 3 months; longer-term open-label follow-up reported sustained benefit in treatment arm
McCormick pooled analysis (2024)
Pooled analysis of 247 participants receiving BVNA showing reductions in conservative care and opioid use up to ~5 years but limited by industry sponsorship and lack of long-term comparator
Cohen et al. (2023) CRFA study
Randomized multicenter comparative effectiveness trial (n=210) showing CRFA superior to standard medical management for chronic SIJ pain at 3 months across pain, ODI, and QoL measures but with more adverse events and limited follow-up
McCormick et al. (2019) CRFA vs traditional RFA trial
Randomized prospective trial (n=43) found higher responder rates with CRFA at 6 months but difference not statistically significant; study underpowered and inconclusive
Cryodenervation evidence (Birkenmaier et al., Staender et al.)
Prospective case series and cohort data show some short- to intermediate-term pain relief for medial branch cryodenervation/cryorhizotomy, but studies lack controls and have mixed durability; overall evidence insufficient to make a recommendation
Guideline recommendation: Cooled RFA grade
NASS: Cooled RFA of sacral lateral branch/dorsal ramus for SIJ pain may be considered — Grade C (poor-quality evidence, Level IV/V); evidence beyond 6 months is lacking

Definitions (operational)

Cooled Radiofrequency AblationApplication 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.

RFA (Radiofrequency ablation)A procedure for spinal pain not regulated by FDA; FDA regulates devices used to perform RFA (product codes: GXD, GXI, GEI).

Revision History

05/01/2025material changeLatest

Coverage Rationale revised — removed language indicating ablation for treating sacroiliac pain is unproven and not medically necessary due to insufficient evidence of efficacy.

05/01/2025material changeLatest

Definition removed — removed the definition of "Conventional (Thermal) Radiofrequency Ablation."

05/01/2025

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Ohio Only)

Policy CodePolicy CSOOIOH.C

Change TypeRevision (05/01/2025) - material and non-material updates

Effective DateMay 1, 2025

Next Review Date

SourceLink

On This Page

Guideline recommendations summary (excerpted)

Selected guideline recommendations and related notes excerpted from cited guideline summaries and regulatory info.

Cooled RFA for sacroiliac joint pain: Cooled RFA of the sacral lateral branch nerves and dorsal ramus of L5 may be considered in patients with sacroiliac joint pain diagnosed with dual diagnostic blocks (Grade C - poor quality evidence; Level IV or V studies).

Grade of recommendation: C (poor quality evidence, Level IV or V studies)

Cryodenervation for zygapophyseal (facet) joint pain: There is insufficient or conflicting evidence to make a recommendation for or against the use of cryodenervation for treatment of zygapophyseal (facet) joint pain.

Grade: insufficient or conflicting evidence

FDA device regulation note: RFA for spinal pain is a procedure and not regulated by the FDA; the FDA regulates RFA devices (product codes GXD, GXI, GEI).

FDA device product codes included

Intraosseous basivertebral nerve RFA (Intracept): Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) for the treatment of spinal pain is unproven and not medically necessary due to insufficient evidence of efficacy.

explicitly listed as unproven and not medically necessary due to insufficient evidence of efficacy

The policy emphasizes that evidence is insufficient for many ablative techniques and relies on systematic reviews, specialty guideline recommendations, FDA device information, and InterQual criteria to form its stance. Where InterQual provides clinical coverage criteria, those are referenced for medical necessity; specialty society guidance and device approvals inform but do not by themselves determine coverage.

Documentation Required

Use InterQual and applicable guidelines

UnitedHealthcare uses InterQual (InterQual CP: Procedures, Neuroablation, Percutaneous) as the primary medical/surgical criteria source. If InterQual lacks applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and Utilization Review Guidelines as approved by the Ohio Department for Medicaid Services.

Prior Authorization

Policy modification and coverage governance

Before applying this policy, check federal, state (OAC), or contractual requirements because they govern in the event of conflict. UnitedHealthcare reserves the right to modify policies and guidelines as necessary; verify any prior authorization or coverage governance requirements that may apply.

Summary of Changes: archived previous policy version CSOO1OHB.

05/01/2025administrative

Updated Clinical Evidence and References sections to reflect the most current information (literature through 2024/2025).