CurrentUnitedHealthcarePolicy CSOOIIDA

Ablative Treatment for Spinal Pain (for Idaho Only)

UnitedHealthcare medical policy for Idaho (including Idaho Medicaid Plus) that defines coverage stance and evidence summary for various ablative treatments for spinal pain (facet, sacroiliac, basivertebral nerve/intraosseous) and lists applicable procedure codes. Policy provides definitions, clinical evidence, guideline summaries, and coding clarifications.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Idaho Only)

Policy CodePolicy CSOOIIDA

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

Key ActionPolicy applies only to the state of Idaho; providers must reference federal, state, or contractual requirements which may govern coverage.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy effective 06/01/2025.

7Unproven techniques listed

6Procedure codes referenced

1State scope (Idaho only)

Coverage Summary

This Idaho-specific UnitedHealthcare medical policy (Policy Number: CSOOIIDA, Effective Date: 2025-06-01) addresses coverage for ablative treatments for spinal pain, including facet, sacroiliac, and basivertebral (intraosseous) nerve procedures. The policy scope applies only to the state of Idaho, including Idaho Medicaid Plus plans.

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Headline evidence findings: systematic reviews, randomized trials, cohort studies, and technology assessments show insufficient evidence to support many alternative ablative techniques (endoscopic RFA, pulsed RFA for many indications, cryoablation, chemical ablation, cooled RFA, laser ablation). For intraosseous basivertebral nerve ablation there are randomized and nonrandomized studies showing benefits versus standard care and mixed results versus sham, but methodological limitations and variable quality temper conclusions.

Relevant Procedure Codes

Procedure / Unlisted / Relevant CPT 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

Provider Actions & Billing Guidance

Documentation Required

State-specific applicability

Policy applies only to the state of Idaho, including Idaho Medicaid Plus plans. Providers must reference and follow applicable federal, state, or contractual requirements when determining coverage and reimbursement.

Billing Rule

Coding clarification for Pulsed RFA

Coding clarification and instructions for Pulsed Radiofrequency Ablation and related procedures.

64999
22899
27299
64628
64629
Use CPT code 64999 for Pulsed Radiofrequency Ablation (per CPT Assistant, 2016).
Report unlisted spine/pelvis/nervous system procedures with appropriate unlisted codes (e.g., 22899, 27299, 64999) as applicable.
Use specific intraosseous basivertebral nerve codes for basivertebral procedures (64628 for first 2 vertebral bodies; 64629 for each additional vertebral body).

Documentation Required

Use of medical evidence and guideline alignment

When requesting coverage, document the clinical rationale and relevant diagnostic/prognostic testing or criteria consistent with cited guidelines and evidence. For example, document results of diagnostic medial branch blocks (positive response) when seeking coverage for medial branch RFA in line with NICE, ASRA, NASS, and ASIPP recommendations.

Background & Evidence Summary

Background: This policy summarizes clinical evidence including systematic reviews, randomized controlled trials, cohort studies, technology assessments, and guideline recommendations regarding multiple ablative spine procedures.

Evidence synthesis: For many ablative techniques (endoscopic radiofrequency/endoscopic rhizotomy, pulsed RFA for numerous spinal indications, cryoablation, chemical ablation, cooled RFA, laser ablation) the policy concludes that there is insufficient evidence of safety and efficacy and that well‑designed randomized controlled trials with larger sample sizes and longer follow-up are needed.

Specific evidence items cited in the policy include a Hayes assessment (updated 2023) that found clinical benefits reported for the Intracept system but deemed RCTs inconclusive and studies of generally poor or fair quality, and an AHRQ comparative effectiveness review (Chou et al., 2021) that concluded evidence was insufficient or mixed for pulsed RFA and cooled RFA for certain indications.

Intraosseous basivertebral nerve ablation evidence: systematic reviews and randomized trials (e.g., Conger et al. 2021; Khalil/INTRACEPT 2019; Fischgrund SMART trial 2018 and extensions) report some clinically meaningful improvements versus standard care and varying results versus sham, but limitations (blinding, crossover, potential bias, industry sponsorship) lead the policy to characterize the evidence as mixed and of variable quality and not definitively established.

Evidence summaries

Hayes assessment (Intracept)Studies show benefits but RCTs inconclusive; Hayes cautious; updated 2023

AHRQ comparative effectiveness review (Chou et al., 2021)Insufficient evidence for pulsed RFA and mixed findings for cooled RFA

Definitions & Procedural Parameters

Conventional (Thermal) Radiofrequency Ablation: Application of continuous high‑frequency electrical current to ablate nerve tissue with target temperature ≥ 60°C, needle placement confirmation by fluoroscopic guidance, and duration ≥ 40 seconds.

Pulsed Radiofrequency Ablation: Technique that delivers intermittent short bursts of energy (rather than continuous energy) using a probe temperature of 42–45°C (per Hayes, 2023).

Procedural thresholds

Pulsed RFA probe temperature42-45 Celsius

Conventional RFA temperature>= 60 Celsius

Conventional RFA duration>= 40 seconds