Pulsed Radiofrequency for the Treatment of Chronic Pain Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|19|2018 POLICY LAST REVIEWED: 12|17|2025 OVERVIEW Pulsed radiofrequency (RF) facet denervation is used to treat neck and back pain originating in facet joints with degenerative changes. Diagnosis of facet joint pain is confirmed by response to nerve blocks. The goal of facet denervation is long-term pain relief. However, the nerves regenerate and, therefore, repeat procedures may be required. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Medicare Advantage Plans Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products Pulsed radiofrequency denervation for the treatment of chronic spinal/back pain is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.
BACKGROUND Pulsed RF consists of short bursts of electrical current of high voltage in the RF range but without heating the tissue enough to cause coagulation. RF is suggested as a possibly safer alternative to thermal RF facet denervation. Temperatures do not exceed 42°C at the probe tip versus temperatures in the 60°C range reached in thermal RF denervation, and tissues may cool between pulses. It is postulated that transmission across small unmyelinated nerve fibers is disrupted but not permanently damaged, while large myelinated fibers are not affected.
Pulsed radiofrequency does not appear to be as effective as conventional radiofrequency denervation, and there is insufficient evidence to evaluate the efficacy of other methods of denervation (eg, alcohol, laser, cryodenervation) for facet joint pain. The evidence is insufficient to determine the effects of the technology on health outcomes. Therefore, these techniques are considered not medically necessary.
CODING Medicare Advantage Plans and Commercial Products At this time there are no specific CPT code(s) to describe pulsed radiofrequency. Providers should file using the unlisted code below: 64999 Unlisted procedure, nervous system RELATED POLICIES Medical Coverage Policy | Pulsed Radiofrequency for the Treatment of Chronic Pain d

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

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REFERENCES

1. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936)
2. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article: Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (A57826)
3. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD): Pain Management (L33622)
4. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article: Billing and Coding: Pain Management (A52863)
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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS