Medicare (CMS LCD/NCD) Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s) prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s) (CPT 64633, 64634, 64635, 64636), for Medicare (NY) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s) (CPT 64633, 64634, 64635, 64636). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Thermal radiofrequency destruction of cervical, thoracic or lumbar medial branch nerves is covered only after the patient meets the general facet gateway criteria (chronic predominantly axial pain >= 3 months, functional deficit on a scale, failed conservative care, no untreated radiculopathy or neurogenic claudication, no non-facet pathology explaining the pain) AND has had TWO medically necessary diagnostic MEDIAL BRANCH BLOCKS, each producing a consistent minimum of 80% SUSTAINED relief of primary (index) pain with duration consistent with the anesthetic used. REPEAT RFA at the same anatomic site requires >= 50% improvement in pain for at least SIX months, or >= 50% consistent improvement in previously painful movements and ADLs versus baseline on the same scale - note this is a 6-month bar, longer than the 3-month bar applied to therapeutic facet injections, and it is a common denial reason when staff assume the two match. Must be performed under CT or fluoroscopic guidance; ultrasound and MRI guidance are not covered. IMPORTANT NEGATIVE: sacroiliac joint denervation / SI-joint RFA is expressly NOT reasonable and necessary under the separate SI-joint LCD - this covered indication is facet (medial branch) RFA only and does not extend to the SI joint. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- Documentation of both diagnostic MBBs with dated percent index-pain relief >= 80% each and duration consistent with the agent
- baseline and follow-up pain plus function scores on the same scale
- levels and laterality treated
- fluoroscopic/CT imaging
- for repeat RFA, evidence of >= 6 months of >= 50% benefit from the prior ablation.
How to submit
- Method: No prior authorization in the office or ASC setting - bill Part B with documentation on file. HOSPITAL OUTPATIENT DEPARTMENT: facet joint interventions require CMS OPD prior authorization (since 07/01/2023); standard decision 7 calendar days.
Sources & verification
- BindingSource — LCD: Facet Joint Interventions for Pain Management (radiofrequency ablation section) (L35936) · effective 2026-04-09.View
- BindingSource — LCD: Sacroiliac Joint Injections and Procedures, section D - SI joint denervation/RFA not reasonable and necessary (L39455) · effective 2026-04-01.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-08-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s)?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s) (CPT 64633, 64634, 64635, 64636). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s)?
Thermal radiofrequency destruction of cervical, thoracic or lumbar medial branch nerves is covered only after the patient meets the general facet gateway criteria (chronic predominantly axial pain >= 3 months, functional deficit on a scale, failed conservative care, no untreated radiculopathy or neurogenic claudication, no non-facet pathology explaining the pain) AND has had TWO medically necessar… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Radiofrequency Ablation, Paravertebral Facet Joint Nerve(s) to Medicare (CMS LCD/NCD)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.