Back Pain Procedures - Radiofrequency Ablation, Facet Joint and Other Injections Form

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Back and Nerve Pain Procedures-Radiofrequency Ablation, Facet and Other Injections Medical Guideline

Service: Back and Nerve Pain Procedures - Radiofrequency Ablation, Facet and Other Injections

PUM 250-0035-1706

Medical Policy Committee Approval Q2-06/2025 Effective Date 09/01/2025

Related Medical Guidelines: • Back and Neck Pain Procedures-Epidural Injections Medical Guideline • Back Pain Procedures-Sacroiliac and Coccydynia Treatments Medical Guideline • Non-covered Services and Procedures Medical Guideline • BOTOX (onabotulinum toxin a) requests are reviewed by our specialty vendor partners – refer to the Drug Prior authorization list.

Coverage for Radiofrequency Ablation, Facet and Other Injections may vary across plans. Refer to the member’s benefit plan document for coverage details.

Pain injection services are subject to medical necessity review. If a limit is not specified in the member’s health plan, the maximum follows the medical necessity guidelines in this policy.
A year is defined as the 12-month period starting from the date of service of the first approved injection.

Description: A facet joint injection is the injection of a local anesthetic with or without steroid into one or more of the facet joints of the spine. A medial branch nerve block is an injection of a local anesthetic near the medial branch nerves that innervate the facet joint. Both the diagnostic facet joint injection and the diagnostic medial branch nerve block are performed to determine whether the facet joint is the source of the pain symptoms, in order to guide future treatment such as neuroablation.
Non-pulsed Continuous Radiofrequency Ablation / Neuroablation (CRFA or RFA) is also known as thermal radiofrequency (RF) ablation, percutaneous radiofrequency facet denervation (RF denervation), RF coagulation, RF lesioning, RF neurolysis, RF facet joint rhizotomy, or facet neurotomy. The procedure is used to interrupt pain impulses. It involves placement of a needle or electrode that destroys the nerves around the facet joint.
For purposes of this policy, non-radicular (axial) pain is pain that does not follow the pattern of radiation from the spine into the extremity along the course of the spinal nerve root. Radicular pain is pain that radiates from the spine into the extremity along the course of the spinal nerve root, following the pattern of the sensory dermatome associated with the irritated nerve root(s) identified. Radicular pain may also be described as a burning or tingling sensation.

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Indications of Coverage:

A. Initial diagnostic facet joint injection / medial branch block (MBB) injection of the cervical, thoracic, or lumbosacral spine region is considered medically necessary when ALL the following criteria (1 through 5 below) are met:

1. Documentation states that the injection(s) is / are for diagnostic purpose in preparation for neuroablation.

2. Documentation of chronic axial neck, middle, or lower back pain symptoms for at least three (3) months without radicular pain symptoms (unless the provider documents the coexistence of both radicular and axial symptoms).

3. Within the last 12 months, the individual has completed a 6-week trial of medications such as anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin, and pregabalin.

4. Within the last 12 months, the individual has completed a 6-week trial of physical therapy (PT) or chiropractic manipulations (performed after the current episode of symptoms started and directed toward the area of symptoms/dysfunction).

   Note: Documentation of therapy administered by a Certified Athletic Trainer or regular participation in a program such as the Arthritis Foundation Exercise Program may also meet medical criteria for therapy.

5. Symptoms are not caused by another identified source (such as disc herniation, radiculitis, spinal stenosis, tumor, infection, or fracture)

   NOTE: The Third Occipital Nerve (TON) is the superficial medial branch of C3 dorsal ramus. It supplies the C2-C3 facet (zygapophyseal joint) while crossing the joint laterally and within the allowed indications if the plan is to do a facet joint RFA for the C2-C3 joint.

   B. A confirmatory (second) facet joint injection / medial branch block (MBB) injection of the cervical, thoracic, or lumbosacral spine region is considered medically necessary when ALL the following criteria (1 through 4 below) are met:

6. All criteria listed in Indications of Coverage, letter A, 1 through 5 above, are met.

7. The initial / first diagnostic facet joint injection/medial branch block must have provided significant (at least 50%) relief from baseline pain scores following the procedure. (If the initial / first diagnostic injection / block does not provide at least 50% relief, a confirmatory / second diagnostic injection or block is considered not medically necessary).

8. The confirmatory (second) diagnostic injection procedures must be performed on the same side and same level as the initial injection.

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4. The confirmatory (second) diagnostic injection procedure must be performed at least one week after the initial injection procedure.

   Note: Medical necessity review is required for each diagnostic facet injection/medial branch block.

   Note: A maximum of two (2) diagnostic facet/medial branch block sessions in the cervical spine region, a maximum of two (2) diagnostic facet/medial branch block sessions in the thoracic spine region, and a maximum of two (2) diagnostic facet/medial branch block sessions in the lumbosacral spine region are considered medically necessary per rolling 12-month period. If the left and right injections are performed on two separate dates of service, this will count as two (2) sessions, unless otherwise approved by the Health Plan’s Medical Director. Services in excess of these thresholds will require Medical Director review on a case by case basis.

   C. Neuroablation of the cervical, thoracic, or lumbosacral spine region is considered medically necessary when ALL of the following (1 through 4 below) are met:

5. All criteria listed in Indications of Coverage; letters A and B above are met.

6. Each level and side to be ablated must have documentation of a positive (provided at least 50% relief of symptoms) diagnostic and confirmatory facet joint injection / medial branch block.

7. If chemical agents (for example phenol or alcohol) are planned for the neuroablation procedure, there must be documentation of the contraindication to thermal neuroablation (for example, spinal instrumentation, pacemaker, implantable cardiac defibrillator).

   Note: No more than 2 neuroablation sessions on the Left side, and 2 Neuroablation sessions on the Right side, per anatomic spinal region (cervical, thoracic, lumbosacral) would be considered medically necessary in a rolling 12- month period. Services in excess of these thresholds will require Medical Director review on a case by case basis.

   Note: Fluoroscopic or CT (computed tomography) guidance is required during medial branch neuroablation, facet injections, and medial branch blocks.

   D. Repeat Neuroablation of the cervical, thoracic, or lumbosacral spine region is considered medically necessary when ALL of the following (1 through 6 below) are met:

8. The criteria listed in Indications of Coverage, letter C, were met for the initial / prior neuroablation.

9. The repeat neuroablation is at the same location (level and side) as the initial / prior neuroablation.

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3. There is documentation of at least a 50% pain reduction that lasted over at least six (6) months following the initial/prior neuroablation.

4. Cervical, thoracic, or lumbosacral spine region symptoms recur after six (6) months and the symptomatology is similar to the previous.

5. The initial / prior neuroablation was performed within eighteen (18) months of the planned repeat neuroablation unless approved by Medical Director.

   Note: Repeat diagnostic facet injection / medial branch block in preparation for repeat neuroablation are considered not medically necessary, unless the prior neuroablation was greater than 18 months ago.

   Note: The requirement for physical therapy / chiropractic manipulation might be waived before repeat neuroablation if the member has had successful neuroablation within the past eighteen (18) months at the same level and side, for the same condition, with relief of at least six (6) months.

   E. Intraarticular facet injections are considered medically necessary when all patient requirements for facet injections are met including:

   • the individual has completed a 6-week trial of medications such as anti- inflammatories, muscle relaxants, analgesics, opioids, gabapentin, and pregabalin within the last 12 months; AND
   • the individual has completed a 6-week trial of physical therapy (PT) or chiropractic manipulations (performed after the current episode of symptoms started and directed toward the area of symptoms/dysfunction) within the last 12 months.

   AND any of the following conditions are documented (1-4):

6. There is suspected inflammatory facetogenic pain due to systemic inflammatory arthropathies clearly documented in the patient’s history and assessment (e.g., rheumatoid arthritis).

7. Denervation is contraindicated (e.g., young person in whom denervation may result in muscle atrophy that can adversely impact their condition (e.g., spondylolisthesis) or ADL’s).

8. Individuals at risk for complications with radiofrequency neurotomy (RFN) treatment (e.g., pacemaker dependent patients and those with automatic implantable cardioverter-defibrillators, presence of another electronic device such as a spinal cord stimulator or intrathecal infusion devices, older individuals on anticoagulation therapy, presence of surgical hardware).

   *For the exceptions listed above only: Facet joint injection at the same anatomic site for recurrent pain may be repeated if the prior injection provided at least 50% reduction in pain with functional improvement of at least 3 months duration. For each covered spinal region, a maximum of four (4) facet joint (IA) sessions are considered medically necessary per rolling 12 months. For each covered spinal region (cervical or lumbosacral), facet joint

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injection may be performed at a maximum of two (2) levels, either unilateral or bilateral, per session. Services in excess of these thresholds will require Medical Director review on a case by case basis.

4. Evidence of nerve root compression due to a facet synovial cyst or large effusion.

   *Patients must meet ALL of the following criteria to receive intraarticular (IA) facet joint injection:

   • Evidence of nerve root compression due to a facet synovial cyst/large effusion when seen on an advanced imaging study (MRI or CT) performed within the previous 12 months that correlates with the clinical findings.
   • Associated moderate-to-severe radicular pain and functional limitations. • Cyst aspiration/rupture may be repeated ONCE within the 12-month period and only if there is consistent pain reduction of 50% or more for a minimum of three (3) months. Services in excess of this threshold will require Medical Director review on a case by case basis.

   The use of intraarticular facet injections is considered not medically necessary for all other indications.

   F. Trigger Point Injections: Trigger point injections do not require medical necessity review.

   G. Repeat Trigger Point Injections: May be performed (up to the maximum listed below).

   Note: A maximum limit of 6 trigger point injection sessions (regardless of location) per rolling 12-month period* may be considered medically necessary. This includes all initial and repeat trigger point injection sessions. Services in excess of this threshold will require Medical Director review on a case by case basis.

   H. Ultrasound guidance may be indicated and medically necessary when used in areas near high-risk tissues (risk of neural, vascular, pulmonary, or other visceral injury) or in deeper anatomical locations such as:

5. The scalenes and other axial neck muscles: If a trigger point injection is performed without image guidance, there is a risk of trespass/damage to the cervical nerve roots, brachial plexus, and numerous vascular structures, including but not limited to the carotid and vertebral arteries.

6. The piriformis and other deep gluteal muscles: There is a risk of trespass/damage of the sciatic nerve in this region if a trigger point injection is performed without image guidance.

   I. Botox is reviewed by our specialty vendor, if Botox is approved by specialty vendor for chemo-denervation then the associated injection codes should also be approved. If Botox

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(chemo-denervation) injection codes are considered denied with the specialty vendor, then the associated injection codes will be considered denied as well.

J. Trigeminal Neuralgia Treatments: Trigeminal Nerve Block and/or Non-Pulsed Radiofrequency Ablation/Neuroablation is considered medically necessary if the member has failed a six month or more trial of pharmacotherapy, had side effects or was unable to tolerate pharmacotherapy.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary.

D. Therapeutic injections including facet joint, medial branch block injections (MBB), zygapophysial joint injection, paravertebral facet joint injection, dorsal root ganglion injection, dorsal ramus injection, posterior ramus injection, and pars interarticularis injections will all be considered experimental, investigational, and unproven to affect health outcomes.

E. Neuroablation is considered investigative/unproven in ANY of the following situations as there is insufficient peer-reviewed scientific literature supporting neuroablation in these situations:

1. When fluoroscopic or computed tomography (CT) guidance is not used during the procedure.

2. For any nerve other than the medial branch nerve or trigeminal nerve, (including but not limited to the greater occipital, genicular, sphenopalatine, supraorbital, cluneal, calcaneal, ilioinguinal, pudendal, and supratrochlear nerves). See also: Non-Covered Services and Procedures medical policy.

3. When there is no diagnostic block to identify the appropriate level and side to be treated.

4. For use of pulsed radiofrequency, pulsed radiofrequency (PRF), or pulsed radiofrequency ablation (PRFA), in all indications.

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F. Injection or neuroablation of lumbar or sacral facets or medial / lateral nerve branches or dorsal rami for treating sacroiliac joint pain will be considered experimental, investigational, and unproven to affect health outcomes. See medical policy, Back Pain: Sacroiliac and Coccydynia Treatments.

G. The following treatments for management of back/ buttocks pain or sacroiliac (SI) joint dysfunction will be considered experimental, investigational, and unproven to affect health outcomes: Sacroiliac joint ablation, sacroiliac neuroablation, diagnostic lateral (sacral) branch nerve blocks.

H. Neuroablation will be considered not medically necessary when it is performed less than six (6) months after a previous neuroablation procedure in the same spinal region.

I. Neuroablation (facet neurotomy) and facet injection / medial branch block (MBB) of the sacral spine (except L5-S1 medial branch block) will be considered experimental, investigational, and unproven to affect health outcomes in both diagnostic and therapeutic settings.

J. Neuroablation (facet neurotomy) and facet injection/medial branch block (MBB) for treatment of occipital neuralgia or headache to include migraine will considered experimental, investigational, and unproven to affect health outcomes.

K. Laser facet denervation will be considered experimental, investigational, and unproven to affect health outcomes.

L. Endoscopic rhizotomy will be considered experimental, investigational, and unproven to affect health outcomes.

M. If the use of fluoroscopic or computed tomography (CT) guidance is not documented, the facet joint injection or medial branch nerve block will be considered experimental, investigational, and unproven to affect health outcomes.

N. A facet joint injection and / or medial branch nerve block performed for primary radicular symptoms or other unexplained neurologic symptoms will be considered not medically necessary.

O. A facet joint arthrogram in conjunction with a facet joint injection is included in the fluoroscopic guidance for the injection, is considered an integral component of the procedure.

P. More than two (2) diagnostic facet/medial branch block sessions per covered spinal region (cervical, thoracic or lumbosacral) in a 12-month period are considered not medically necessary unless approved by Medical Director. If the left and right injections are performed on two separate dates of service, this will count as two (2) sessions.

Q. During a facet/medial branch block session, treatment of more than 3 levels will be considered not medically necessary.

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R. If more than one type of pain treatment is requested / performed on the same day, only one type will be considered medically necessary at the discretion of the health plan. The other will be considered not medically necessary.

S. Cryoablation for the treatment of facet joint pain will be considered experimental, investigational, and unproven to affect health outcomes.

T. Ultrasound guidance for facet injection, medial branch block, or trigger point injection (except those listed above) will be considered experimental, investigational, and unproven to affect health outcomes.

U. Performing a session involving the lumbar, thoracic, and/or cervical regions on the same date of service is considered not medically necessary.

V. Ablation, cryotherapy, or treatment intended to cause nerve dysfunction (e.g., iovera, Coolief) will be considered experimental, investigational, and unproven to affect health outcomes.

W. The following nerve blocks or neuroablations including, but not limited to, sphenopalatine ganglion, greater occipital, dorsal root ganglion and/or dorsal ramus (except for third occipital nerve block as noted above in Indications of Coverage), genicular, peripheral nerve for knee pain, and cluneal will be considered experimental, investigational, and unproven to affect health outcomes.

X. Ganglion impar block or radiofrequency thermocoagulation for the treatment of chronic coccydynia will be considered experimental, investigational, and unproven to affect health outcomes.

Y. Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., The Intracept Procedure / Intracept Intraosseous Nerve Ablation System®) will be considered experimental, investigational, and unproven to affect health outcomes.

Z. Occipital Neurectomy/Nerve Decompression (supra orbital, supratrochlear, zygomaticotemporal or greater occipital nerve) for treatment of headache or occipital neuralgia will be considered experimental, investigational, and unproven to affect health outcomes.

AA. Dry needling of trigger points will be considered experimental, investigational, and unproven to affect health outcomes.

BB. Monitored anesthesia care (MAC) for adults for trigger point injections, medial branch
blocks, facet joint injections will be considered not medically necessary.

CC. Hydro dissection for the treatment of Neuropathic pain is considered experimental, investigational, unproven to affect health outcomes.

DD. Stem cells and/or Platelet Rich Plasma (PRP) Injections are considered experimental, investigational, unproven to affect health outcomes.

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EE. Intradiscal injection of any substance (to include steroid, stem cells, platelet rich plasma [PRP], methylene blue, Via Disc NP anti-TNF-alpha agents such as etanercept) for treatment of chronic pain is considered experimental, investigational, unproven to affect health outcomes.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Office notes include documentation of the symptoms that suggest the presence of facet joint pathology and exclude any correctable spinal pathology condition (for example, spinal cord tumor, severe spinal stenosis, infection, or intervertebral disc disease requiring surgical treatment, such as a large disc herniation). Documentation of the failure of conservative therapies (Physical therapy notes, chiropractic treatment notes, medication trials). For the second (confirmatory) injection / block: Office notes documenting the results of the first injection / block. Documentation of the effect of the initial / first injection may include a patient diary or office telephone records. • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Radiofrequency Ablation, Facet and Other Injections are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical policy.

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Medical Policy Review History:

Implemented 10/01/16, 08/21/17, 10/01/18, 10/01/19, 9/01/20, 09/01/21, 06/01/22, 09/01/23, 06/01/24, 09/01/25 Medical Policy Committee Approval 06/03/16, 06/16/17, 06/15/18, 05/31/19, 5/28/20, 05/27/21, 05/26/22, 05/17/23, 05/30/24, 06/26/25 Reviewed

06/16/17, 06/15/18, 05/31/19, 5/28/20, 05/27/21, 05/26/22, 05/17/23, 05/30/24, 06/26/25 Revised Errata* correction 10/25/16. 06/16/17 (includes title change), 06/15/18, 05/31/19, 01/28/2021, 05/27/2021 Developed 06/03/016- New consolidated policy developed

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 20560 NEEDLE INSERTION(S) WITHOUT INJECTION(S); 1 OR 2 MUSCLE(S) 20561 NEEDLE INSERTION(S) WITHOUT INJECTION(S); 3 OR MORE MUSCLES 64400 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR) 64405 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID, GREATER OCCIPITAL NERVE
64450 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH 64454 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED 64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL 64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

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64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL 64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64624 DESTRUCTION BY NEUROLYTIC AGENT, GENICULAR NERVE BRANCHES INCLUDING IMAGING GUIDANCE, WHEN PERFORMED 64625 RADIOFREQUENCY ABLATION, NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, 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, INCLUIDNG ALL IMAGING GUIDANCE; EACH ADDITIONAL VERTEBRAL BODY, LUMBAR OR SACRAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT 64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

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64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 64999 UNLISTED PROCEDURE, NERVOUS SYSTEM 0213T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL 0214T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0215T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0216T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL 0217T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0218T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 01513ZZ DESTRUCTION OF CERVICAL NERVE, PERCUTANEOUS APPROACH 01513ZZ DESTRUCTION OF CERVICAL NERVE, PERCUTANEOUS APPROACH 01583ZZ DESTRUCTION OF THORACIC NERVE, PERCUTANEOUS APPROACH 01593ZZ DESTRUCTION OF LUMBAR PLEXUS, PERCUTANEOUS APPROACH

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015A3ZZ DESTRUCTION OF LUMBOSACRAL PLEXUS, PERCUTANEOUS APPROACH 015B3ZZ DESTRUCTION OF LUMBAR NERVE, PERCUTANEOUS APPROACH 015B3ZZ DESTRUCTION OF LUMBAR NERVE, PERCUTANEOUS APPROACH 015D3ZZ DESTRUCTION OF FEMORAL NERVE, PERCUTANEOUS APPROACH 015G3ZZ DESTRUCTION OF TIBIAL NERVE, PERCUTANEOUS APPROACH 015H3ZZ DESTRUCTION OF PERONEAL NERVE, PERCUTANEOUS APPROACH 015Q3ZZ DESTRUCTION OF LUMBOSACRAL PLEXUS, PERCUTANEOUS APPROACH 015Q3ZZ DESTRUCTION OF SACRAL PLEXUS, PERCUTANEOUS APPROACH 015R3ZZ DESTRUCTION OF SACRAL NERVE, PERCUTANEOUS APPROACH 3E0R3GC INTRODUCTION OF OTHER THERAPEUTIC SUBSTANCE INTO SPINAL CANAL, PERCUTANEOUS APPROACH 3E0R3KZ INTRODUCTION OF OTHER DIAGNOSTIC SUBSTANCE INTO SPINAL CANAL, PERCUTANEOUS APPROACH 3E0T3BZ INTRODUCTION OF ANESTHETIC AGENT INTO PERIPHERAL NERVES AND PLEXI, PERCUTANEOUS APPROACH 3E0T3GC INTRODUCTION OF OTHER THERAPEUTIC SUBSTANCE INTO PERIPHERAL NERVES AND PLEXI, PERCUTANEOUS APPROACH 3E0T3TZ INTRODUCTION OF DESTRUCTIVE AGENT INTO PERIPHERAL NERVES AND PLEXI, PERCUTANEOUS APPROACH