Radiofrequency (RF) Denervation

Pulsed radiofrequency ablation for spinal or back pain is unproven, and therefore not a covered benefit.
Non-pulsed radiofrequency denervation for the treatment of chronic cervical and lumbar facet pain is a covered, limited benefit when the following specific criteria are met:

• No prior spinal fusion surgery at the vertebral level being treated.
• Low back or neck pain suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations.      
• The pain does not radiate to other parts of the body. 
• Pain has failed to respond to at least three months of conservative management (for example, acetaminophen, nonsteroidal anti-inflammatory medications, manipulation, physical therapy or home exercise program). 
• A trial of controlled diagnostic medial branch blocks under fluoroscopic guidance has resulted in at least a 50 percent reduction in pain. 
• If there has been a prior successful RF denervation, a minimum time of six months has elapsed since prior RF treatment (per side, per anatomical level of the spine).

Radiofrequency denervation for the treatment of thoracic facet pain is unproven, and therefore not a covered benefit. No authorization is required for beneficiaries, excluding active duty service members, however a benefit review is recommended.

To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the request.