Facet Joint and Sacroiliac Joint Denervation

This policy covers image‑guided thermal radiofrequency (RF) denervation of cervical (C3–4 and below) and lumbar facet joints/medial branch nerves for disabling, non‑radicular neck or low back pain attributed to facet joint degeneration when all medical necessity criteria are met, including failure of ≥6 weeks of conservative care. Coverage requires two separate fluoroscopically guided diagnostic medial branch blocks on different days with ≥80% pain relief using local anesthetic only, no prior spinal fusion at the treated level, and at least 6 months between repeat RFs for the same side/level; RF and other denervation methods (pulsed RF, chemodenervation, laser, cryo) are considered investigational or not covered for indications (including SIJ and radicular pain) that do not meet these criteria.

"Nonpulsed RF denervation of cervical facet joints (C3-4 and below) when ALL specified medical necessity criteria are met."