Description of Procedure or Service

Knee osteoarthritis (OA) is a prevalent condition among older adults, characterized by chronic pain and functional impairment. Treatment primarily focuses on symptom relief and functional improvement, as most interventions do not alter disease progression.

Nonsurgical management includes:

• Lifestyle modifications (e.g., exercise, weight loss)
• Supportive devices
• Pharmacologic agents (e.g., acetaminophen, NSAIDs)
• Nutritional supplements (e.g., glucosamine, chondroitin)
• Intra-articular therapies (e.g., viscosupplementation, corticosteroid injections)
  • Corticosteroid injections may be considered when NSAIDs are ineffective or contraindicated due to gastrointestinal risks. If conservative measures fail, surgical options such as arthroscopy or total knee replacement may be indicated.
• Radiofrequency ablation (RFA) is a minimally invasive treatment proposed to temporarily reduce pain with various causes. This technique is also known as radiofrequency lesioning, radiofrequency nerve ablation (RFNA), radiofrequency neurotomy, denervation, or rhizotomy. Different types include:
  • Conventional RFA
  • Cooled radiofrequency ablation/denervation (also known as C-RFA)
  • Pulsed RFA
• Cryoablation,
• Chemical ablation,
• Genicular nerve blocks (GNB)

Policy Statement

Minimally invasive ablation procedures, including but not limited to genicular nerve block, radiofrequency ablation, cryoablation and alcohol/anesthetic/steroid injections (treatment prior to knee replacement or following knee replacement or instead of knee replacement) are considered experimental/investigational. It has not been scientifically demonstrated to improve patient clinical outcomes. BCBSNC does not provide coverage for investigational services or procedures. Radiofrequency ablation of peripheral nerves to treat pain is considered investigational for all applications and diagnoses. BCBSNC does not provide coverage for investigational services or procedures. Cryoneurolysis of peripheral nerves to treat pain is considered investigational for all applications and diagnoses. BCBSNC does not provide coverage for investigational services or procedures. Ablation of peripheral nerves to treat pain is considered investigational for all applications and diagnoses, except for facet joint pain. BCBSNC does not provide coverage for investigational services or procedures.

Definitions

• Cryoablation: This may also be known as cryosurgery, cryodenervation, cryogenic neuroablation, cryoneurolysis, or cryoanalgesia.
• Genicular nerve blocks (GNB): A GNB generally involves the injection of an anesthetic agent (e.g., lidocaine, bupivacaine) and may be performed to determine suitability for RFA.
  • During the procedure radiofrequency (RF) energy delivers heat to the target nerve thereby creating a lesion that stops pain input to the central nervous system. Prior to planning the RFA procedure, a diagnostic genicular nerve block is conducted to ensure that the patient is a suitable candidate for RFA, usually under fluoroscopic or ultrasonographic guidance.
• Radiofrequency ablation (RFA): A minimally invasive treatment proposed to temporarily reduce pain with various causes. This technique is also known as radiofrequency lesioning, radiofrequency nerve ablation (RFNA), radiofrequency neurotomy, denervation, or rhizotomy. Different types include:
  • Conventional RFA
  • Cooled radiofrequency ablation/denervation (also known as C-RFA)
  • Pulsed RFA

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

Indications for Coverage

Not applicable

When Coverage Wil Not be Approved

Minimally invasive ablation procedures, including but not limited to RFA, cryoablation and alcohol/anesthetic/steroid injections, are considered investigational for all applications and diagnoses.

Radiofrequency ablation of peripheral nerves to treat pain is considered investigational for all applications and diagnoses.

Cryoneurolysis of peripheral nerves to treat pain is considered investigational for all applications and diagnoses.

Ablation of peripheral nerves to treat pain is considered investigational for all applications and diagnoses, with the exception of facet joint pain

Billing/ Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

Applicable code(s): 64454, 64624, 64640, 64999

The Plan may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Special Notes

• NeuroTherm^® NT 2000 (NeuroTherm, Inc.) received 510K clearance in 2011. The FDA determined that this device was substantially equivalent to existing devices for use in lesioning neural tissue in the peripheral nervous system. vExisting predicate devices included the NeuroTherm NT 1000 (cleared in 2006), Stryker Interventional Pain RF Generator and RF Electrodes and Medical Coverage Policy: 4 Cannulae (2004), and Cosman G4 RF Generator (cleared in 2008).
• The Stryker MultiGen^™ 2 RF Generator System received 510K clearance in 2017 for “coagulation of soft tissues in orthopedic, spinal, and neurosurgical applications. Examples include, but are not limited to: Facet Denervation, Trigeminus Neuralgia, Peripheral Neuralgia and Rhizotomy.”¹ This system may be used for both pulsed and non-pulsed/conventional RFA, depending on the setting.
• The iovera° system (Myoscience, Inc) originally received 510K clearance in 2014 to produce lesions in peripheral nervous tissue to block pain. In 2017 (K1737637) indications for use were expanded specifically for the knee, stating that the device could also be used “for the relief of pain and symptoms associated with osteoarthritis of the knee for up to 90 days.”²
• Coolief Cooled RF Probe (Halyard Health, Inc.) received 510K clearance (K163461) in 2017 for “creating radiofrequency lesions of the genicular nerves for the management of moderate to severe knee pain of more than 6 months with conservative therapy, including medication, in patients with radiologicallyconfirmed osteoarthritis (grade 2-4) and a positive response (≥50% reduction in pain) to a diagnostic genicular nerve block the relief of chronic, moderate to severe, knee pain caused by osteoarthritis (OA).”³

CPT instructions state that code 64624 “requires the destruction of each of the following genicular nerve branches: superolateral, superomedial, and inferomedial. If a neurolytic agent for the purposes of destruction is not applied to all of these nerve branches, report 64624 with modifier 52.” 

References

1. Casadaban LC, Mandell JC, Epelboym Y. Genicular artery embolization for osteoarthritis related knee pain: a systematic review and qualitative analysis of clinical outcomes. Cardiovasc Intervent Radiol. 2021; 44(1):1-9.
2. Chen AF, Khalouf F, Zora K, et al. Cooled radiofrequency ablation compared with a single injection of hyaluronic acid for chronic knee pain: a multicenter, randomized clinical trial demonstrating greater efficacy and equivalent safety for cooled radiofrequency ablation. J Bone Joint Surg Am. 2020a; 102(17):1501-1510.
3. Chen AF, Khalouf F, Zora K, et al. Cooled radiofrequency ablation provides extended clinical utility in the management of knee osteoarthritis: 12-month results from a prospective, multi-center, randomized, cross-over trial comparing cooled radiofrequency ablation to a single hyaluronic acid injection. BMC Musculoskeletal Disord. Jun 09 2020b; 21(1): 363
4. Chen AF, Mullen K, Casambre F, et al. Thermal nerve radiofrequency ablation for the nonsurgical treatment of knee osteoarthritis: a systematic literature review. J Am Acad Orthop Surg. 2021; 29(9):387-396.
5. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011; 152(3):481-487.
6. Blue Cross Blue Shield Corporate Medical Policy – Ablation and Neural Therapy Procedures for Headache and Pain Management, effective date 08/2015 accessed via Ablation and Neural Therapy Procedures for Headache and Pain Management | Providers | Blue Cross NC
7. Blue Cross Blue Shield Blue Care Network: Michigan Medicare Advantage Medical Policy Cryoablation or Cryoneurolysis (e.g., iovera System) of Peripheral Nerves -MA effective date 7/17/2024 accessed on 09/12/2025
8. Blue Cross Blue Shield Blue Care Network Michigan Medicare Advantage: Genicular Nerve Blocks effective date 3/1/2025 accessed on 9/12/2025
9. Providence Health Plan – Medicare: Genicular Nerve Blocks and Nerve Ablation for Knee Pain effective date 01/01/2025, accessed on 9/12/2025
10. Network Health WI Medicare: Nerve Blocks and Ablation Therapy for the Treatment of Pain, effective date 03/01/2021 accessed on 9/12/2025
11. Centers for Medicare and Medicaid Services (CMS) Proposed Local Coverage Determination (LCD) Peripheral Nerve Blocks and Procedures for Chronic Pain accessed on 09/15/2025 via Proposed LCD - Peripheral Nerve Blocks and Procedures for Chronic Pain (DL40263)
    https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=40262&ver=8
12. Centers for Medicare and Medicaid Services (CMS) Proposed Local Coverage Reference Article (LCA) Billing and Coding: Peripheral Nerve Blocks and Procedures for Chroni Pain accessed on 09/15/2025 via Draft Article - Billing and Coding: Peripheral Nerve Blocks and Procedures for Chronic Pain (DA60298)
    https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=60297&ver=3

Policy Implementation/Update Information

Revision Date: November 18, 2025, Newly created policy. (AR)

Approval Dates

Medical Coverage Policy Committee: November 20, 2025

Physician Advisory Group Committee: November 18, 2025