Medical Policy: 07.01.41
Original Effective Date: May 2008
Reviewed: March 2016
Revised: March 2016
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Pulsed radiofrequency has been used as a non - or minimally destructive technique alternative to radiofrequency heat lesions in the treatment of a variety of pain syndromes. Pulsed radiofrequency may also be performed in attempt to denervate the occipital nerve (greater or lesser), upper cervical nerve (e.g. cervical nerve, also known as C2), supraorbital, supratrochlear or sphenopalatine ganglion. The proposed goal is to “shut off” the pain signals that are sent to the brain from the joints and nerves. An additional purported objective is to reduce the likelihood of, or to delay, any recurrence that may occur by selectively destroying pain fibers without causing excessive sensory loss, motor dysfunction or other complications.
Pulsed radiofrequency uses short bursts of radiofrequency current, rather than a continuous current. The heat from PRF is not enough to cause the tissue to coagulate. PRF denervation causes the transmission across small unmyelinated nerve fibers to be disrupted, but not permanently damaged. This is because the temperature will not exceed 42°C versus 60°C reached in continuous RFA.
The mechanism by which PRF controls pain is unclear, but it may involve a temperature-independent pathway mediated by a rapidly changing electrical field. The available evidence on the effectiveness of PRF in the treatment of patients with various chronic pain syndromes is largely based on retrospective, case series studies. Its clinical value needs to be examined in well-designed, randomized controlled trials with large sample size and long term follow up.
Current evidence is insufficient to permit conclusions about long term benefits and harms of pulsed radiofrequency (PRF). The current evidence is limited to data from small, short-term randomized controlled trials, case series and retrospective reviews which are considered unreliable due to methodological limitations. There is a lack of long term data comparing PRF with conventional treatments, so it is not known if PRF offers any treatment advantage over conventional treatments. In addition, there are no clinical practice guidelines from U.S. Professional associations that recommend the use of PRF. Therefore, pulsed radiofrequency (PRF) is considered investigational for the treatment of pain from any cause.
Practice Guidelines and Position Statements
American Society of Interventional Pain Physicians
Updated guidelines on interventional techniques in the management of chronic spinal pain from the American Society of Interventional Pain Physicians (ASIPP) were published in 2013:
- Lumbar spine
- The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections.
- For sacroiliac interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy.
- Cervical Spine
- Guideline does not mention the use of pulsed radiofrequency ablation.
- Evidence for therapeutic facet joint intervention is faire for conventional cervical radiofrequency neurotomy.
- Thoracic Spine
- Guideline does not mention the use of pulsed radiofrequency ablation.
- Evidence is limited for radiofrequency neurotomy.
A number of radiofrequency generators and probes have been cleared for marketing through the U.S. Food and Drug Administration (FDA) 510(k) process.
See also medical policy 07.01.58 Facet Joint Denervation*
See also medical policy 07.01.66 Ablative Treatments for Occipital Neuralgia, Chronic Headaches and Atypical Facial Pain*
Pulsed radiofrequency is considered investigational in the treatment of various pain syndromes including but not limited to the following:
- Chronic head and facial pain
- Neck pain
- Occipital neuralgia
- Discogenic pain
- Low back pain
- Zygapophyseal joint pain
- Facet and sacroiliac joint dysfunction/arthropathy
- Complex regional pain syndrome/reflex sympathetic dystrophy
- Pudenal neuralgia
- Sacro-iliac joint pain
- Trigeminal neuralgia
- Osteoarthritis of knee
- Shoulder pain
- Thoracic pain
- Lumbo-sacral radicular syndrome
Current evidence is insufficient to permit conclusions about long term benefits and harms of pulsed radiofrequency (PRF). The current evidence is limited to data from small, short-term randomized controlled trials, case series and retrospective reviews. There is a lack of long term data comparing PRF with conventional treatments, so it is not known if PRF offers any treatment advantage over other conventional treatments. In addition, there are no clinical practice guidelines from U.S. Professional associations that recommend the use of PRF. Therefore, pulsed radiofrequency (PRF) is considered investigational for the treatment of pain from any cause.as the evidence is insufficient to permit conclusions regarding the impact of pulsed radiofrequency on health outcomes.
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
64999 Unlisted procedure, nervous system (The American Medical Association’s CPT Editorial Panel decided in June 2005 that the unlisted CPT code 64999 should be used for pulsed RF treatment as opposed to other specific codes)
Cahana A, Van Zundert J, Macrea L et al. Pulsed radiofrequency: current clinical and biological literature available. Pain Med. 2006 Sep-Oct;7(5):411-23.
Lindner R, Sluijter ME, Schleinzer W. Pulsed radiofrequency treatment of the lumbar medial branch for facet pain: a retrospective analysis. Pain Med. 2006 Sep-Oct;7(5):435-9.
Tekin I, Mirzai H, Ok G et al. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clin J Pain. 2007 Jul-Aug;23(6):524-9.
Van Zundert J, Patijun J, Kessels A et al. Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized trial. Pain. 2007 Jan;127(1-2):173-82. Comment in: Expert Rev Neurother. 2007 May;7(5):471-2. Pain. 2007 Jan;127(1-2):3-4.
Boswell MV, Trescot AM, Datta S et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111.
Simopolous TT, Kraemer J, Nagda JV et al. Response to pulsed and continuous radiofrequency lesioning of the dorsal root ganglion and segmental nerves in patients with chronic lumbar radicular pain. Pain Physician. 2008 Mar;11(2):137-44.
Van Boxem K, van Bilsen J, de Meij N et al. Pulsed radiofrequency treatment adjacent to the lumbar dorsal root ganglion for the management of lumbosacral radicular syndrome: a clinical audit. Pain Med. 2011 Aug 3. doi:10.1111/j.1526-4637.2011.01202.x. [Epub ahead of print].
Nagda JV, Davis CW, Bajwa ZH et al. Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain. Pain Physician. 2011 Jul-Aug; 14(4):371-6.
Todorov L. Pulsed radiofrequency of the sural nerve for the treatment of chronic ankle pain. Pain Physician. 2011 May-Jun; 14(3):301-4.
Korkmaz OK, Capaci K, Eyigor C et al. Pulsed radiofrequency versus conventional transcutaneous electrical nerve stimulation in painful shoulder: a prospective, randomized study. Clin Rehabil. 2010 Nov; 24(11):1000-8. Epub 2010 Aug 4.
Taverner MG, Ward TL, Loughnan TE. Transcutaneous pulsed radiofrequency treatment in patients with painful knee awaiting total knee joint replacement. Clin J Pain. 2010 Jun;26(5):429-32.
Eyigor C, Eyigor S, Korkmaz OK et al. Intra-articular corticosteroid injections versus pulsed radiofrequency in painful shoulder: a prospective, randomized, single-blinded study. Clin J Pain. 2010 Jun;26(5):386-92.
Vanelderen P, Rouwette T, De Vooght P et al. Pulsed radiofrequency for the treatment of occipital neuralgia: a prospective study with 6 months of follow-up. Reg Anesth Pain Med. 2010 Mar-Apr; 35(2):148-51.
Hansen H, Manchikanti L, Simopoulos TT et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May-Jun; 15(3):E247-78.
Gofeld M, Restrepo-Garces CE, Theodore BR et al. Pulsed radiofrequency of suprascapular nerve for chronic shoulder pain: a randomized double-blind active placebo-controlled study. Pain Pract. 2012 May 4. doi: 10.1111/j.1533-2500.2012.00560.x. [Epub ahead of print]
Guo L, Kubat NJ, Nelson TR et al. Meta-analysis of clinical efficacy of pulsed radiofrequency energy treatment. Ann Surg. 2012 Mar; 255(3):457-67.
Conner-Kerr T, Isenberg RA. Retrospective analysis of pulsed radiofrequency energy therapy use in the treatment of chronic pressure ulcers. Adv Skin Wound Care. 2012 Jun;25(6):253-60.
Choi GS, Ahn SH, Cho YW et al. Short-term effects of pulsed radiofrequency on chronic refractory cervical radicular pain. Ann Rehabil Med. 2011 Dec;35(6):826-32. Epub 2011 Dec 30.
Fukui S, Rohof O. Results of pulsed radiofrequency technique with two laterally placed electrodes in the annulus in patients with chronic lumbar discogenic pain. J Anesth. 2012 Aug;26(4):606-9. Epub 2012 Apr 5.
Nagda JV, Davis CW, Bajwa ZH et al. Retrospective review of the efficacy and safety of repeated pulsed and continuous radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain. Pain Physician. 2011 Jul-Aug;14(4):371-6.
Werner MU, Bischoff JM, Rathmell JP et al. Pulsed radiofrequency in the treatment of persistent pain after inguinal herniotomy: a systematic review. Reg Anesth Pain Med. 2012 May-Jun;37(3):340-3.
Zhang J, Shi DS, Wang R. Pulsed radiofrequency of the second cervical ganglion (C2) for the treatment of cervicogenic headache. J Headache Pain. 2011 Oct;12(5):569-71. Epub 2011 May 25.
Manchikanti L, Abdi S et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II. Pain Physician 2013 Apr; 16: S49-283.
American Society of Anesthesiologists. Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology April 2010; 112: 1-1.
National Institute of Health. NIH Public Access. Pulsed Radiofrequency for Chronic Pain, David Byrd M.D., MPH and Sean Mackey, M.D., PhD. January 2008; 12(1):37-41.
. Radiofrequency Therapies in Chronic Pain.
Journal of Pain Research: Treatment of Trigeminal Neuralgia: Role of Radiofrequency Ablation. J Pain Res. 2010; 3:249-254. Published online December 12, 2010 doi:10.2147/JPRS14455
PubMed. 3D-CT Guided Pulsed Radiofrequency Treatment for Trigeminal Neuralgia. Pain Practice.2014 Jan; 14(1):16-21. doi: 10.1111/papr.12041. Epub2013 Feb 21.
Matthew David VanderHoek, Hieu T. Hoang, Brandon Goff, Ultrasound Guided Greater Occipital Nerve Blocks and Pulsed Radiofrequency Ablation for Diagnosis and Treatment of Occipital Neuralgia. Anesthesiology and Pain Medicine. 2013 September; 3(2):256-9.
American Society of Interventional Pain Physicians (ASIPP). An Update of Comprehensive Evidence Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physicians 2013; 16:S49-S283 ISSN 1533-3159.
American Pain Society. Guideline for Evaluation and Management of Low Back Pain, Evidence Review 2009.
American Academy of Pain Medicine. Pulsed Radiofrequency Lesioning of Pudendal Nerve in Patient with Chronic Pain: A Case Report 2012.
Pain Medicine News. Evidence Based Review of Radiofrequency Ablation Techniques for Chronic Sacroiliac Joint Pain.
Pain Medicine News Special Edition December 2013, Pulsed Radiofrequency in Treatment of Peripheral Neuralgias
Nicholas Manolitsis, M.D., Foad Elahi, M.D., Pulsed Radiofrequency for Occipital Neuralgia, Pain PhysicianExternal Site
Slavin Konstantin, Nersesyan Hrachya et. al. Current Algorithm for the Surgical Treatment of Facial Pain, Head and Face Medicine July 2007
American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine, Practice Guideline for Chronic Pain Management, Anesthesiology 2010 Vol 112. No 4
. Radiofrequency Treatment in Chronic Pain, Expert Rev Neurother 2010;10(3):469-474.
Akbas MertExternal Site
, Gunduz Emel, et.al. Sphenopalatine Ganglion Pulsed Radiofrequency Treatment in Patients Suffering from Chronic Face and Head Pain, April 2014
Cohen S, Peterlin LB, Fulton L, et. al. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain 2015 December; 156(12):2585-2594
Taverner MG, Ward TL, Loughnan TE. Transcutaneous pulsed radiofrequency treatment in patients with painful knee awaiting total knee joint replacement. Clin J Pain. 2010;26(5):429-432
Chua NH, Vissers KS, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications – a review. Acta Neurochir (Wien). 2011 Apr 153(4):763-71
Zakrzewska JM. Akram H. Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Cochrane Database Syst Rev 2011 Sep 7(9): CD007312. PMID 21901707
Taverner MG, Loughnan TE, Soon CW. Transcutaneous application of pulse radiofrequency treatment for shoulder pain. Pain Pract 2013 Apr 13(4):310-5
Nagar VR, Birthi P, Grider JS, Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for management of cervicogenic headache. Pain Physician 2015 Mar-Apr 18(2):109-30. PMID 25794199
van Boxem K, van Bilsen J, de Meij N, et. al. Pulsed radiofrequency treatment adjacent to the lumbar dorsal root ganglion for the management of lumbosacral radicular syndrome: A clinical audit. Pain Medicine 2011;12: 1322-1330
Shanthanna H, Chan P, McChesney J, et. al. Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain: a randomized, placebo-controlled pilot study. Journal of Pain Research 2014:7 47-55
Manolitsis N, Elahi F. Pulsed Radiofrequency for Occipital Neuralgia. Focused Review. Pain Physician 2014; 17: E709-E717
March 2016 - Annual Review, Policy Revised
October 2015 - Interim Review, Policy Revised
April 2015 - Annual Review, Policy Renewed
May 2014 - Annual Review, Policy Revised
July 2013 - Annual Review, Policy Renewed
September 2012 - Annual Review, Policy Renewed
September 2011 - Annual Review, Policy Renewed
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.