CMM-208: Ablations/Denervations of Facet Joints and Peripheral Nerves

Radiofrequency joint denervation/ablation (CT- or fluoroscopy-guided) is medically necessary for facet‑mediated cervical, thoracic, or lumbar axial pain only when all criteria are met: ≥3 months of pain, ≥4 weeks of failed conservative care (or documented contraindication), two sequential diagnostic facet/medial branch blocks at the same level with ≥80% relief for the expected anesthetic duration, imaging excludes other causes, the target motion segment is unfused (or an unfused level above/below a prior fusion or suspected pseudoarthrosis), limits on levels (C2‑3 to L5‑S1), up to three contiguous facet levels per side (six if bilateral), no more than two procedures per rolling 12 months with ≥6 months between procedures, and repeat RFA requires prior ≥50% relief lasting ≥12 weeks. Pulsed, cooled, cryo, chemical, endoscopic, laser techniques, peripheral nerve destructions for chronic foot/heel/hip/knee/shoulder pain, third occipital nerve for headaches, and RFA of the basivertebral or sacroiliac joint nerves are considered not medically necessary or investigational.