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

Radiofrequency joint denervation/ablation of facet joints (C2-3 through L5-S1) is covered for facet‑mediated cervical, thoracic, or lumbar axial pain only when ALL criteria are met: ≥3 months of pain, ≥4 weeks of conservative therapy (or documented contraindication), two sequential diagnostic medial branch/facet blocks at the same levels with ≥80% relief for the anesthetic’s expected duration, imaging/clinical evaluation excluding other causes, unfused posterior motion segment(s) (exception for suspected pseudoarthrosis), CT/fluoroscopic guidance, and required documentation; repeat denervation is allowed ≥6 months after prior if prior provided ≥50% relief for ≥12 weeks. Excluded/investigational or not medically necessary are pulsed RFA, endoscopic RFA, cryo/chemical/laser/cooled techniques, peripheral nerve destruction for chronic/foot/hip/knee/shoulder pain, basivertebral and SI joint ablation, and the policy limits procedural frequency and levels (max 3 contiguous levels per side/6 if bilateral, ≤2 procedures at same level in a rolling 12 months, and only one invasive spinal/interventional procedure per date of service).