Percutaneous Neuroablation Form

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Percutaneous Neuroablation Medical Policy Updated Revision Effective: 7/1/2025 Policy Number: UM1005POL

Approval Date: 5/13/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Percutaneous neuroablation is a procedure that destroys neural tissue to relieve pain. These procedures may be performed using one of several mechanisms. Chemical neuroablation involves the percutaneous administration of phenol or alcohol around a nerve to denervate it. Percutaneous application of heat (radiofrequency neuroablation) or cold (cryoneurolysis) to the nerve is called thermal neuroablation. Radiofrequency neuroablation is restricted to neurolysis of central neural tissue, while cryoneurolysis may be used for neurolysis of peripheral nerves.

 Line of Business

Commercial: • Health New England (HNE) has adopted InterQual* criteria for : CP: Procedures, Percutaneous Neuroablation.

Medicaid – BeHealthy:
• Health New England (HNE) has adopted InterQual* criteria for : CP: Procedures, Percutaneous Neuroablation.

Medicare:
• Health New England (HNE) has adopted InterQual* criteria for : CP: Procedures, Percutaneous Neuroablation.

• HNE follows Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L35936) for Radiofrequency Ablation. https://www.cms.gov/medicare-coverage-database/search.aspx

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

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Policy

I. Percutaneous Neuroablation

A. Health New England has adopted the following InterQual criteria.

• CP: Procedures, Percutaneous Neuroablation.

B. Percutaneous Neuroablation for treatment of any other indications or using modalities other than those covered in criteria above are considered EXPERIMENTAL and INVESTIGATIONAL.

C. Radiofrequency neuroablation (non-pulsed) for the treatment of chronic pain from following conditions, regardless of the type of neuroablative technique used is considered EXPERIMENTAL and INVESTIGATIONAL due to lack of supporting medical literature :

1. Coccygodynia (coccydynia); OR
2. Complex regional pain syndrome (CPRS)/reflex symptomatic dystrophy; OR
3. Dorsal root ganglia; OR
4. Genicular nerve; OR
5. Hip, knee or pelvic/pelvis osteoarthritis/pain; OR
6. Morton’s neuroma; OR
7. Post herniorrhaphy groin pain; OR
8. Presacral neurectomy for treatment of pain related to endometriosis; OR
9. Sural nerve for ankle pain; OR
10. Terminal (peripheral) nerve ending (e.g. diabetic neuropathy); OR
11. Trigger point(s); OR
12. Definitive clinical and/or imaging findings identifying a condition requiring surgical treatment; OR
13. Identified specific causes of spinal pain (e.g., disc herniation) requiring definitive treatment; OR

14. Diagnostic facet blocks and denervation procedures performed on the same day.

    D. RFA by any ablative techniques other than non-pulsed RFA including but not limited to the following are considered EXPERIMENTAL and INVESTIGATIONAL.

15. Pulsed radiofrequency therapy of the facet nerves of the cervical, thoracic or lumbar region and sacral nerve root or dorsal root ganglion (CPT code 64999).

16. Radiofrequency ablation with temperature less than 60 degrees Celsius (including COOLIEF cooled RF probe and COOLIEF Sinergy).

17. Endoscopic radiofrequency ablation (rhizotomy).

18. Cryoablation (cryodenervation, cryoneurolysis, cryosurgery).

19. Chemical ablation (including but not limited to alcohol, phenol or sodium morrhuate) except when used for severe cancer pain.

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

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Policy Guidelines and Definitions

Radiofrequency ablation (RFA): May also be referred to as nonpulsed radiofrequency ablation, percutaneous radiofrequency neuroablation, radiofrequency coagulation, radiofrequency denervation, radiofrequency lesioning, radiofrequency neuroablation, radiofrequency neurotomy or rhizotomy (articular rhizolysis). This percutaneous procedure utilizes radiofrequency current/energy to heat and ablate/denervate the target nerve. This technique involves the constant application of energy, usually at 80-85oC via an image-guided needle electrode inserted through the skin to the affected nerve. Examples of devices used for RFA include, but may not be limited to, the Baylis Pain Management Radiofrequency Generator and G4 RF Generator.

Chemical neurolysis: May also be referred to as chemical ablation, chemical denervation or chemodenervation, involves the injection of neurolytic agents (eg, alcohol, hypertonic saline, phenol). This proposed treatment option for chronic pain generally results in a permanent ablation of the nerve.

Cooled radiofrequency denervation: Is a modification of conventional radiofrequency ablation (RFA), in that it maintains the tissue temperature immediately adjacent to the electrode at 60oC while the target tissue (nerve) is heated to 75oC or higher. This purportedly allows for a larger volume of treated tissue without the risk of damage to the adjacent tissue. Examples of devices used for this procedure include, but may not be limited to, the Accurian RF Platform (when used in the cooled RF mode), COOLIEF Cooled RF Probe and Coolief Sinergy (Coolief Sinergy is specifically for the sacroiliac joint).

Cryosurgery: May also be referred to as cryoablation or cryodenervation and is a technique of using extreme cold to destroy tissue, which is cooled to below -20oC by a probe circulating liquid nitrogen.

Cryotherapy: Is similar to cryosurgery, in that it uses extreme cold to destroy tissue, but is generally used to specifically target cardiac tissue or peripheral nerves. The CryoNB (cryo nerve block) therapy is an example of cryotherapy; it is performed with the CryoICE cryoSPHERE cryoablation probe and is proposed as a method for blocking postoperative pain by temporarily ablating peripheral nerves.

Intracept Intraosseous Nerve Ablation System: Is a specialized radiofrequency ablation device, which has been granted US Food & Drug Administration (FDA) approval strictly for destruction of the basivertebral nerve of the L3-S1 vertebrae. It is proposed as a treatment option for low back pain.

Laser ablation: Is proposed as a noninvasive treatment, which uses laser energy to ablate a peripheral nerve.

Pulsed radiofrequency denervation: Is another proposed alternative to traditional radiofrequency neurotomy. It delivers short bursts of radiofrequency current instead of a continuous flow, which purportedly allows the needle to remain relatively cool so that the tissue temperature decreases slightly between each burst, reducing the risk of destroying nearby tissue. Examples of devices used for this procedure include, but may not be limited to, the Accurian RF Platform, IonicRF Generator, MultiGen 2 RF Generator System or NeuroTherm NT2000IX (when any of these devices are used in pulsed mode).

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Coding Guidance

Code
Description
PA 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid No 62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic No 62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) No 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch No 64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale No 64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring No 64620 Destruction by neurolytic agent, intercostal nerve No 64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Yes 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral Yes 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) Yes 64630 Destruction by neurolytic agent; pudendal nerve No 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Yes 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) Yes 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Yes 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) Yes 64640 Destruction by neurolytic agent; other peripheral nerve or branch No 64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus No 64681 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus No 64999 Unlisted procedure, nervous system Not covered when used to report procedures listed as experimental/i nvestigational CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

National Coverage Determination (NCD). Induced lesions of nerve tracts (160.1) NCD - Induced Lesions of Nerve Tracts (160.1) (cms.gov)

Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L35936) LCD - Facet Joint Interventions for Pain Management (L35936) (cms.gov)

Manchikanti, L, Kaye A., Soin, A, Albers, A, et.al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines (May 23, 2020).

https://pubmed.ncbi.nlm.nih.gov/32503359/

   https://asipp.org/wp-content/uploads/2020/11/REF1MA1.pdf

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med, 2022 Jan;47(1):3-59. https://pubmed.ncbi.nlm.nih.gov/34764220/

Radiofrequency denervation for chronic low back pain: a systemic review of randomized controlled trials, (July 28, 2014)
https://pubmed.ncbi.nlm.nih.gov/25068973/

Leggett L, Soril L, Lorenzetti D, et al, Radiofrequency Ablation for chronic low back pain: A systemic review of randomized controlled trials, Pain Research and Management, 2014 Sept-Oct; 19(5): e146–e153.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197759/

Burnham RS, Hollistski S, Dimnu I. A prospective outcome study on the effects of the facet joint radiofrequency denervation on pain, analgesic intake, disability, satisfaction, cost, and employment. Arch Phys Med Rehabil 2009.90; 201-5.
https://www.sciencedirect.com/science/article/abs/pii/S0003999308015888
Hansen H, Manchikanti L, et.al. A Systemic Evaluation of the Therapeutic Effectiveness of Sacroiliac Joint Interventions, Pain Physician 2012; 15:E247-E278 • ISSN 2150-1149.

  https://pdfs.semanticscholar.org/196b/aa0ce72bb1d8d7139198c054d355494fea06.pdf

Hayes, Radiofrequency Ablation for Facet Joint Denervation for Chronic Low Back Pain, Annual review April 23,

2021. https://evidence.hayesinc.com/report/dir.radiolowback324

      Christensen S, Sehgal N. What is the correlation between facet joint radiofrequency outcome and response to comparative medial branch blocks? Pain Physician. 2016;19:163-172.

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Arsanious D, Gage E, Koning J, et al. Pulsed dose radiofrequency before ablation of medial branch of the lumbar dorsal ramus for zygapophyseal joint pain reduces post-procedural pain. Pain Physician. 2016;19:477-484.

Cheng J, Chen S, Zimmerman N, Dalton J, LaSalle G, Rosenquist R. A new radiofrequency ablation procedure to treat sacroiliac joint pain. Pain Physician. 2016;19:603-619.

Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain – an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:1066-

1077. Cohen S, Raja S. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106:591-614.

      Clinical Evidence Assessment. Accurian Radiofrequency Ablation System (Medtronic plc.) for treating nerve pain. https://www.ecri.org. Published October 1, 2020.

      Clinical Evidence Assessment. Coolief Cooled Radiofrequency System (Avanos Medical, Inc.) for treating hip pain. https://www.ecri.org. Published May 5, 2021.

      Clinical Evidence Assessment. Coolief Cooled Radiofrequency System (Avanos Medical, Inc.) for treating knee osteoarthritis. https://www.ecri.org. Published November 17, 2020.

      Clinical Evidence Assessment. Intracept System (Relievant Medsystems, Inc.) for treating chronic low-back pain. https://www.ecri.org. Published October 13, 2020. Updated August 10, 2022.

      Clinical Evidence Assessment. Iovera System (Pacira Biosciences, Inc.) for reducing postoperative pain. https://www.ecri.org. Published September 5, 2018. Updated November 25, 2020.

      Evidence Report. Radiofrequency ablation for chronic spinal pain. https://www.ecri.org. Published April 7, 2010.

      Hayes, Inc. Evidence Analysis Research Brief. Coolief Cooled RF (Avanos Medical Inc.) for treatment of back pain. https://evidence.hayesinc.com. Published October 14, 2022.

      Hayes, Inc. Evidence Analysis Research Brief. Radiofrequency ablation for sacroiliac joint denervation for chronic low back pain. https://evidence.hayesinc.com. Published April 25, 2022.

      Boswell MV, Trescot AM, Datta S, et al., Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician. 2007; 10:7-111.

      http://www.ncbi.nlm.nih.gov/pubmed/17256025

      Policy Implementation

      Approved by the Medical and Pharmacy Policy Committee

      Kate McIntosh MD MBA

      Chief Medical Officer

      Saad Usmani MD MBA

      Medical Director

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Date Update 04/2024 New Policy, replacing Radiofrequency ablation (UM433POL). InterQual criteria used for all lines of business except Medicare (LCD - L35936). References updated. Added 64628, 64629 as covered when criteria is met.
04/2025 No Criteria Changes. CPT 64625 move from E&I to covered with PA.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. 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 the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.