Prior authorization request form Form

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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definition Radiofrequency ablation (RFA) (aka facet neurotomy, facet rhizotomy or articular rhizolysis) is a percutaneous treatment using radiowave-induced heat to create a lesion in a spinal sensory nerve. The goal of RFA is to relieve pain by interrupting the transmission of pain signals from the sensory nerve to the brain. Guideline Members with moderate to severe cervical, thoracic or lumbar spinal pain are eligible for coverage of radiofrequency ablation (RFA) when the following criteria are met. (Note: See Intracept for intraosseous nerve ablation for vertebrogenic low back pain) Supportive documentation that must be presented to the Plan includes the medical record on history, physical and radiographic evaluations.

Pain is secondary to facet joint origin, as evidenced by the absence of nerve root compression and radicular pain1
Neuroradiologic studies do not confirm any disc herniation infection or tumor
1 Facet pain may occur in association with radiculopathy and in the presence of herniated disc.

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Pain is refractory for a 6-month period and has failed to respond to 3 months of conservative management (e.g., nonsteroidal anti-inflammatory/opioid medications, chiropractic therapy/physical therapy and a home exercise program)
Demonstration of symptom relief secondary to a trial of 2 controlled diagnostic medial branch blocks provided under a standard alternating protocol of alternating short and long-acting anesthetic blocks. No IV sedation or opioids should be used during this
Intracept Intraosseous Basivertebral Nerve Ablation System Criteria for Chronic low back pain (CLBP) (Commercial and Medicare)
Skeletal maturity
CLBP for at least 6 months
Failure to respond to 3 months of conservative management (e.g., nonsteroidal anti-inflammatory/opioid medications, chiropractic therapy/physical therapy and a home exercise program)
Vertebrogenic back pain as evidenced by Type 1 or Type 2 Modic changes on MRI — endplate hypo- intensity (Type 1) or hyperintensity (Type 2) on T1 images plus hyperintensity on T2 images (Type 1) invol ving in the endplates between L3 and S1 Limitations and Exclusions
Members should have no history of spinal fusion surgery in the vertebral level being treated.
Use of thermal RFA to destroy any other spinal structure other than the medial branch nerve is considered investigational and hence not covered
Denervation procedures of the sacroiliac joint are considered experimental/investigational
Non-thermal RF modalities for medial branch ablation including chemical, low-grade thermal, or pulsed radiofrequency ablation (CPT 64625) are not covered
As results may be transient, a repeat RFA is considered medically necessary when a prior treatment has been successful as follows:  Maximum of 2 times over a 12-month period per side and level (i.e., no more than 2 procedures per year)  Achievement of ≥ 50% pain reduction in conjunction with functional improvement
The following treatment protocols are not considered to be medically necessary:  > 1 treatment per level per side within a 6-month period  > 2 treatments per year  Long-term, repeated or maintenance. (Requests for treatment beyond the 1st year will be medical-director-reviewed) Note: RFA performed to the medial branch nerves for a maximum of 3 facet levels, or denervation of 5 spinal medial branches unilaterally, will be allowed on a single visit.
The following procedures are not considered medically necessary, as they are investigational:  Automated percutaneous lumbar discectomy (APLD)/automated percutaneous nucleotomy.  Coblation® Nucleoplasty™, disc nucleoplasty, decompression nucleoplasty plasma disc decompression  Cryoneurolysis

Page 3 of 6  Devices for anular repair (e.g., Inclose™ Surgical Mesh System, Xclose™ Tissue Repair System).  Endoscopic epidural adhesiolysis  Epiduroscopy, epidural myeloscopy, epidural spinal endoscopy  Intervertebral disc biacuplasty  Intraosseous basivertebral nerve radiofrequency ablation (Intracept System) (covered Commercial and Medicare only)  Laser ablation  Laser discectomy (percutaneous or laparoscopic), laser-assisted disc decompression (LADD), laser disc decompression  Percutaneous epidural adhesiolysis, percutaneous epidural lysis of adhesions  Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), intradiscal radiofrequency.
 Thermomodulation, percutaneous radiofrequency thermomodulation, Intradiscal electrothermal annuloplasty (IDET)/ percutaneous intradiscal radiofrequency thermoc oagulation)/ SpineCATH™  Pulsed radiofrequency  Racz procedure (covered Medicare only, 62263 and 62264)  Radiofrequency thermocoagulation for chronic coccydynia Procedure Codes
62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days (Medicare Only)
62264 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day (Medicare Only) 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Commercial and Medicare only)
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) (Commercial and Medicare Only)
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
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)

ICD-10 Diagnoses M12.88 Other specific arthropathies, not elsewhere classified, other specified site M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region M47.12 Other spondylosis with myelopathy, cervical region M47.13 Other spondylosis with myelopathy, cervicothoracic region

Page 4 of 6 References Carragee, E., Persistent Low Back Pain, The New England Journal of Medicine, Volume 352, No. 18, May 5, 2005. Chou, Roger. Subacute and chronic low back pain: Nonsurgical interventional treatment. In UpToDate, Atlas, Steve J (Ed), Waltham, MA, 2010. Diwan, A., and S. Khan, Chronic low back pain: issues and management, part I, Orthopedic Clinics of North America, Vol. 34, No. ix,

Doleys, D., and B. Dinoff, Psychological aspects of interventional therapy, Anesthesiology Clinics of North America, Vol. 21, 767-783,
Hayes Inc. Hayes Medical Technology Directory. Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; August 2009. M47.14 Other spondylosis with myelopathy, thoracic region M47.15 Other spondylosis with myelopathy, thoracolumbar region M47.16 Other spondylosis with myelopathy, lumbar region M47,811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region M47.812 Spondylosis without myelopathy or radiculopathy, cervical region M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region M53.0 Cervicocranial syndrome M53.1 Cervicobrachial syndrome M53.81 Other specified dorsopathies, occipito-atlanto-axial region M53.82 Other specified dorsopathies, cervical region M53.83 Other specified dorsopathies, cervicothoracic region M53.85 Other specified dorsopathies, thoracolumbar region M54.2 Cervicalgia M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M54.5 Low back pain M54.6 Pain in thoracic spine M54.81 Occipital neuralgia M62.830 Muscle spasm of back M71.30 Other bursal cyst, unspecified site M71.38 Other bursal cyst, other site

Page 5 of 6 Hayes Inc. Hayes Medical Technology Directory. Radiofrequency Ablation for Cervical and Thoracic Back Pain. Lansdale, PA: Hayes, Inc.; October 2009. Helm S, Hayek SM, Benyamin R, Manchikanti L. Systematic review of the effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician 2009; 12(1): 207-232 Hooten, M., et al., Radiofrequency Neurotomy for Low Back Pain: Evidence-Based Procedural Guidelines, Pain Medicine, Vol. 6, No. 2, 2005. J. Gossner : Radiofrequency denervation of the facet joints in chronic low back pain- a short review. The Internet Journal of Radiology. 2010 Volume 12 Number 1. Lord S.M., et al. Percutaneous Radio-Frequency Neurotomy for Chronic Cervical Zygapophyseal-Joint Pain. The New England Journal of Medicine Vol. 335 No. 23, 1721-1726, December 5, 1996.
Mikeladze, G., et al., Pulsed radiofrequency application in treatment of chronic zygopophyseal joint pain, The Spine Journal, Vol. 3, Issue 5, September 2003. Niemisto L, Kalso E, Malmivaara A, et al. Radiofrequency denervation for neck and back pain. A systemic review of randomized controlled trials (Cochrane Review) in: The Cochrane Library, Issue 1, 2003. Oxford: Update Software. Date of most recent substantive amendment: 5 April 2002. Spinal Pain: Evidence-Based Practice Guidelines, Pain Physicians, Vol. 8, No.1, 1-47, 2005. Staats, P., Interventional pain management, Anesthesiology Clinics of North America, Vol. 21, Issue 4, Xiii-xiv, December 2003. U.S. Department of Health and Human Services, National Center for Health Statistics, Health, United States, 2005 With Chartbook on Trends in the Health of Americans, 2005. Maas ET, et al. Radiofrequency denervation for chronic low back pain. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD008572. DOI: 10.1002/14651858.CD008572.pub2. Manchikanti L, Hirsch JA, Falco FJ, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World Journal of Orthopedics 2016;7(5):315-337. DOI: 10.5312/wjo.v7.i5.315. Lee CH, Chung CK, Kim CH. The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trials. Spine Journal 2017;17(11):1770-1780. DOI: 10.1016/j.spinee.2017.05.006. Official Disability Guidelines, 2010. TWC PAIN. Facet Joint Medial Branch Radiofrequency Neurotomy for Low Back Pain Conditions. Manchikanti KN, Atluri S, Singh V, Geffert S, Sehgal N, Falco FJ. An update of evaluation of therapeutic thoracic facet joint interventions. Pain Physician 2012;15(4):E463-E481. Joo YC, Park JY, Kim KH. Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain. Journal of Anesthesia 2013;27(3):390-5. Hayes Inc. Health Technology Assessment. Ganglion Impar Block or Radiofrequency Thermocoagulation for Treatment of Chronic Coccydynia. Lansdale, PA: Hayes Inc.; July 2022. Hayes Inc. Evolving Evidence Review. Intracept Intraosseous Nerve Ablation System (Relievant Medsystems Inc.) for Treatment of Adults With Low Back Pain. Lansdale, PA: Hayes Inc.; July 2021. North American Spine Society (NASS). Basivertebral nerve ablation: defining appropriate coverage positions. North American Spine Society. 2023; spine.org. Accessed January 23, 2026. Specialty-matched clinical peer review. Revision History Company(ies)

  DATE

REVISION EmblemHealth Feb. 14, 2025 Transferred policy content to individual company branded template ConnectiCare EmblemHealth Jan. 12, 2024 Added Intracept Commercial coverage Added Intracept criteria applicable to Commercial and Medicare

Page 6 of 6 Company(ies)

  DATE

REVISION ConnectiCare EmblemHealth Aug. 12, 2022 Added radiofrequency thermocoagulation for chronic coccydynia to Limitations/Exclusions as investigational ConnectiCare May 13, 2022 ConnectiCare adopts clinical criteria of its parent corporation EmblemHealth EmblemHealth Apr. 18, 2022 Added Medicare coverage for intraosseous basivertebral nerve radiofrequency ablation eff. 01/01/2022 EmblemHealth Dec. 10, 2021 Added “infection or tumor” to indication: Neuroradiologic studies do not confirm any disc herniation infection or tumor Clarified repeat RFA language Added intraosseous basivertebral nerve radiofrequency ablation (Intracept System) as investigational EmblemHealth Mar. 8, 2019 Added coverage for thoracic pain EmblemHealth Oct. 12, 2018 Noted that facet pain may occur in association with radiculopathy and in the presence of herniated disc EmblemHealth Nov. 13, 2015 Thoracic pain indication removed EmblemHealth Jul. 14, 2017 Added Interna® Dermal Regeneration FENIX™ Continence Restoration System as investigational

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Prior authorization request form Form

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