CMM-208: Ablations/Denervation's of Facet Joints and Peripheral Nerves

Radiofrequency denervation/ablation of facet joints (C2-3 to L5-S1) is covered for facet-mediated cervical, thoracic, or lumbar axial pain only when all criteria are met: ≥3 months pain, ≥4 weeks conservative therapy (or documented contraindication), two sequential diagnostic medial branch/facet injections with ≥80% relief for the expected anesthetic duration, imaging/clinical exclusion of other causes, unfused target motion segments (exception for suspected pseudoarthrosis), CT/fluoroscopic guidance, limits of no more than three contiguous levels (six if bilateral) per session, and repeats ≥6 months after prior with documented ≥50% relief lasting ≥12 weeks. Pulsed/cooled RFA, cryoablation, chemical/laser/endoscopic techniques, intraosseous basivertebral nerve ablation, sacroiliac joint nerve ablation, third occipital nerve for headaches, and procedures or indications not meeting these criteria are considered not medically necessary or investigational.

"A radiofrequency joint denervation/ablation is considered medically necessary for facet-mediated cervical, thoracic, or lumbar axial pain resulting from disease, injury, or surgery when ALL of the ..."