Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation 7.01.42

By October 15, 2025: Billing and clinical teams must implement the following: (1) Create prior authorization workflow requiring verification of ALL criteria in Policy Statement I (A-E) before claim submission, including documentation of 3-month pain duration, 4+ weeks conservative treatment, and two sequential diagnostic blocks with 80% relief; (2) Update encounter forms and EMR templates to capture required documentation fields for facet-mediated pain diagnosis, conservative treatment dates/types, and diagnostic block results; (3) Configure billing system to deny or route for manual review any claims for radiofrequency procedures performed: without CT/fluoroscopic guidance, more than 2x per level in 12 months, on more than 3 contiguous levels in same session, on same day as other invasive procedures, or above C2-C3 or below L5-S1; (4) Create internal denial messages for investigational procedures (pulsed RF, cryoablation, cooled RF, endoscopic RF, chemical ablation, laser ablation, sacroiliac joint RF ablation, basivertebral nerve ablation); (5) Providers and coding staff must not bill investigational techniques listed in Policy Statement V; (6) Implement 6-month minimum interval tracking between repeat procedures at same level; (7) Claims submitted without meeting these criteria will be denied for failure to meet medical necessity requirements. This policy supersedes any prior Excellus guidance on these procedures.