Clinical Review Criteria Update – Radiofrequency Ablation
Posted on March 30, 2021
Policy Number: UM433POL
Effective Date: 6/1/2021
LOB Affected: Commercial, Medicare, Medicaid
Policy Type: Medical
- Added 11 definitions
- I., Criteria for Approval
Added LCD link to use for all lines of business to determine if member meets criteria
- Original Sections I. and II.
The information originally included in Sections I. and II. was deleted.
- II., What is Not Covered? (Formerly Section III.)
- Added the question mark to the section heading
- B., Added 7.: “Radiofrequency denervation for sacroiliac joint pain”
- C.: Deleted all the ICD-10 codes
- CPT Codes
Updated to indicate 64624 and 64625 are not covered benefits for HNE members
- Source/Citation Section
- Sources confirmed and updated as needed
- Added 2 new resources
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