CurrentUnitedHealthcarePolicy CSOOIPAP

Ablative Treatment for Spinal Pain (for Pennsylvania Only)

UnitedHealthcare medical policy (Pennsylvania only) on ablative treatments for spinal pain describing coverage rationale, definitions, clinical evidence, and applicable procedure/diagnosis codes for various ablation techniques (pulsed RFA, endoscopic RFA/rhizotomy, cryoablation, cooled RFA, chemical ablation, laser ablation, intraosseous basivertebral nerve RFA). This is Part 1 of 2; contains evidence summaries, definitions, and coding guidance.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Pennsylvania Only)

Policy CodePolicy CSOOIPAP

Change TypeCoverage rationale added

Effective DateJun 1, 2025

Next Review Date

Key ActionBe aware that policy now states intraosseous basivertebral nerve ablation (e.g., Intracept) is considered unproven and not medically necessary; prior authorization requests should reflect this coverage position.

POLICY UPDATE CHANGES

Coverage Rationale: Added language specifying intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) is unproven and not medically necessary due to insufficient evidence of efficacy.

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

Updated Clinical Evidence and References sections to reflect current information.

Archived previous policy version CSOOIPA.O

7Ablation techniques unproven / not medically necessary

1New coverage exclusion added (Intracept)

1State-specific policy (Pennsylvania)

MultipleProfessional society guidance cited

Coverage Summary

This UnitedHealthcare medical policy applies only to Pennsylvania and addresses ablative treatments for spinal pain, including multiple radiofrequency, cryo, chemical, and laser techniques. The policy takes a mixed coverage stance: several facet joint nerve ablation techniques are explicitly described as unproven and not medically necessary due to insufficient evidence of efficacy. The policy history dated 06/01/2025 documents a material change adding a statement that intraosseous basivertebral nerve radiofrequency ablation (e.g., Intracept) is unproven and not medically necessary because of insufficient evidence.

Key thresholds and scope

Pain severity threshold (NICE)Visual analog scale >= 5

Clinical response threshold for repeat RFA>= 50% pain relief at 3 months

State applicabilityPennsylvania only

Policy part1 of 2

Medical Necessity and Unproven Techniques

Not Medically Necessary / Unproven 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
listed as unproven / not medically necessary
Pulsed Radiofrequency Ablation of the facet nerves of the cervical, thoracic, or lumbar region, sacral nerve root, or dorsal root ganglion
listed as unproven / not medically necessary
Cryoablation (cryodenervation, cryoneurolysis, cryosurgery, or cryoanesthesia)
listed as unproven / not medically necessary
Chemical ablation (including but not limited to alcohol, phenol, or sodium morrhuate)

Coding

Listed 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
64999	Unlisted procedure, nervous system

FDA product codes for RFA devices (informational)mixed

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)

Provider Actions & Billing Guidance

Documentation Required

State applicability & exceptions

This policy applies only to the state of Pennsylvania. Requests for services that do not meet the policy criteria will be evaluated case-by-case and may follow Pennsylvania Exceptions under Pennsylvania Code Title 55 Chapter 1101.

Pennsylvania Code Title 55 Chapter 1101

Billing Rule

Coding clarification for pulsed RFA

CPT Assistant (2016) specifies that CPT code 64999 should be used to report pulsed radiofrequency ablation procedures.

64999

Background, Evidence Summary, and Definitions

The policy summarizes evidence and definitions for multiple modalities: pulsed radiofrequency ablation, endoscopic rhizotomy (endoscopic RFA), cryoablation, cooled radiofrequency ablation, chemical ablation, laser ablation, and intraosseous basivertebral nerve (BVN) radiofrequency ablation (Intracept). It provides brief descriptions of the techniques and references to clinical studies, systematic reviews, and technology assessments for each modality.

Overall, the policy judges the body of evidence as insufficient or mixed for many of these techniques. For pulsed RFA, endoscopic rhizotomy, cryoablation, chemical and laser ablation, and cooled RFA the policy states evidence is limited and insufficient to establish safety and efficacy. For intraosseous BVN RFA (Intracept) some randomized trials and systematic reviews report benefits versus sham or standard care, but the policy notes methodological limitations, potential industry sponsorship, and inconsistent results; therefore evidence is considered limited and, per the 2025 revision, Intracept is characterized as unproven and not medically necessary.

Evidence source	Summary
Hayes HTA / Evidence reviews
Multiple Hayes reports (2019–2024) concluded evidence is insufficient or low quality for many ablative techniques; mixed findings for cooled RFA and basivertebral nerve ablation (Intracept).
Randomized trials cited
Key RCTs include the SMART trial (Fischgrund et al. 2018) and the manufacturer‑sponsored Khalil et al. (2019) Intracept trial showing some benefit versus sham or standard care but with limitations (blinding issues, crossover, industry sponsorship).
AHRQ reviews
AHRQ comparative effectiveness reviews (Chou et al. 2021) found insufficient evidence for pulsed RFA and mixed results for cooled RFA (short‑term benefit but limited evidence beyond 6 months).
Randomized sham‑controlled trials with crossover
SMART sham‑controlled trial reported clinically meaningful improvements versus baseline with durability to 2 years; high crossover limited longer term between‑group comparisons (8% at 2 years and 10% at 5 years underwent surgery).
Hayes assessments
Hayes evidence summaries and HTAs (including 2021 report and 2024 updates) reviewed Intracept and other ablation modalities and concluded minimal to mixed support, highlighting study limitations and need for further high‑quality research.

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.

Revision History

06/01/2025material_changeLatest

06/01/2025removed_definition

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

06/01/2025supporting_information_updated

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Pennsylvania Only)

Policy CodePolicy CSOOIPAP

Change TypeCoverage rationale added

Effective DateJun 1, 2025

Next Review Date

On This Page

listed as unproven / not medically necessary

Cooled Radiofrequency Ablation

listed as unproven / not medically necessary

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

listed as unproven / not medically necessary

Sacroiliac and Basivertebral Nerve Ablation

Specific ablation indications described as unproven / not medically necessary due to insufficient evidence:

ANY of the following

Ablation for treating sacroiliac pain
listed as unproven / not medically necessary
Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) for treatment of spinal pain
listed as unproven / not medically necessary

ref':

Coverage Rationale (policy revision summary)

Policy statement added in 06/01/2025:

ALL of the following

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

ref':

Professional society recommendations and practice guidance (informational criteria)

Extracted recommendations from major societies — not direct coverage criteria but inform clinical appropriateness:

informational

ASIPP: The level of evidence is II with moderate strength of recommendation for cervical and lumbar RFA
ASIPP: The level of evidence is III with weak–moderate recommendation for thoracic RFA
ASIPP: Suggested frequency for facet joint nerve ablation is 6 months or longer (maximum 2 times per year) provided ≥50% relief maintained for 5–6 months
ASRA: Medial branch blocks should be the prognostic screening test of choice before lumbar facet RFA
Consensus (Cohen et al. 2020): Repeat RFA recommended for recurrence in patients with good initial outcome (typically ≥50% pain relief at 3 months) and repeat procedures no more than two times per year
NICE: Consider RFA for CLBP when non-surgical treatment failed; moderate–severe localized back pain (VAS ≥5); pain likely from medial branch nerve; only after positive diagnostic medial branch blockVAS ≥5
NASS: Suggests thermal RFA for LBP from zygapophyseal joints; more reliable with stringent diagnostic criteria; relief durable for at least six months
NASS: Cooled RFA of sacral lateral branch nerves may be considered in SIJ patients with dual diagnostic blocks (grade: poor quality evidence)
NASS: Insufficient evidence to recommend for or against cryodenervation for zygapophyseal joint pain

ref':

Billing Rule

Use of unlisted codes for specific procedures

When reporting the Intracept procedure or cooled radiofrequency ablation, use an appropriate unlisted procedure code for the anatomic site (for example, unlisted spine or pelvis/hip codes) as listed in the policy's applicable codes.

22899
27299

Documentation Required

Diagnostic medial branch block before RFA

Before performing lumbar facet radiofrequency ablation, perform and document a positive diagnostic medial branch block as the prognostic screening test of choice; document the percent pain relief achieved and the duration of relief.

Document percent pain relief and duration after diagnostic medial branch block

Documentation Required

Frequency limits for repeat RFA

Document the patient's initial response to RFA (threshold of ≥50% pain relief) and limit repeat medial branch neurotomies to no more than twice per year, with intervals of at least 6 months between procedures, consistent with ASIPP and consensus guidance.

Initial response threshold: ≥50% pain relief
Maximum repeats: 2 times per year
Minimum interval between procedures: ≥6 months

Prior Authorization

Coverage determination for intraosseous basivertebral nerve ablation

The policy states that intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) is considered unproven and not medically necessary due to insufficient evidence of efficacy; prior authorization requests should reflect this coverage determination.

Effective revision date: 2025-06-01

Intraosseous radiofrequency ablation of the basivertebral nerve (Intracept)A procedure targeting the basivertebral nerve within the vertebral body for chronic low back pain; specifically noted as unproven and not medically necessary in this policy update.

Supporting information updated: Updated Clinical Evidence and References sections to reflect current information.

06/01/2025archived

Administrative archival: Archived previous policy version CSOOIPA.O.