References

1. Medicare Claims Processing Manual 100-4, Chapter 32, Sections 68 & 69; Effective date: 1/1/15; Revised 10/11/2024 Accessed via Internet site Medicare Claims Processing Manual (cms.gov); viewed on 10/24/2025.
2. Medicare Managed Care Manual; Chapter 4; Section 90.5; Effective 01/01/2015; Creating new Guidance; Viewed on line at MCM Chapter 4 (cms.gov); viewed on 10/24/2025. 
3. Medicare Managed Care Manual Ch 4, Section 10.7.2, Effective 04/22/2016; accessed via MCM Chapter 4 (cms.gov) on 11/24/2025. 
4. Medicare Benefit Manual Ch 14, Section 20, Effective 1/1/2015; accessed via Medicare Benefit Policy Manual (cms.gov) on 11/24/2025.
5. CMS Manual System: Pub 100-02 Transmittal 198, Change Request 8921. Effective Date 1/1/15;  accessed via http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R198BP.pdf online on 11/24/2025.
6. MLN Matters MM8921; CR Release Date 11/6/2014, Effective Date 1/1/2015, accessed via Medicare Coverage of Items and Services in Category A and B Investigational Device Exemption (IDE) Studies (cms.gov) on11/24/2025.
7. Blue Medicare “Evidence of Coverage”, 2023; Chapter 4: Medical Benefits Chart (What is covered and what you pay), Section 3.1- Services we do not cover (exclusions). Accessed via Forms library | Members | Medicare | Blue Cross NC viewed on 11/24/2025.
8. BCBSNC Corporate Medical Coverage Policy: Investigational (Experimental) Services; last reviewed on 11/2024; Medical and Scientific Evidence; viewed online at Investigational (Experimental) Services | Providers | Blue Cross NC ; viewed on 11/24/2025.
9. Social Security; Exclusions from Coverage; viewed online atSocial Security Act §1862, viewed on 11/24/2025.
10. 2014 Medicare Explained; Wolters Kluwer, Law and Business; 2014 CCH Incorporated. ISBN: 978-0-8080-3738-5; page 273-276—old reference. 
11. Medicare Local Coverage Determination for Category III CPT Codes –Wisconsin Physicians Service Insurance Corporation (L35490) Effective date: 10/01/2015; accessed via LCD - Non-Covered Category III CPT Codes (L34555) (cms.gov).viewed on 11/24/2025 .
12. Medicare Local Coverage Determination Article (LCA) Billing and Coding Article (A56902); Effective Date 08/29/2019 accessed via Article - Billing and Coding: Category III Codes (A56902) viewed on 11/24/2025
13. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets via HCPCS Quarterly Update | CMS
14. Centers for Medicare & Medicaid Services (CMS), ICD-10-CM Official Guidelines for Coding and Reporting ICD-10 | CMS
15. Centers of Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 23-Fee Schedule administration and coding Requirements accessed via  Medicare Claims Processing Manual; viewed on 11/24/2025

Center for Medicare and Medicaid Services, Medicare NCCI Medically Unlikely Edits (MUEs) accessed via Medicare NCCI Medically Unlikely Edits | CMS viewed on 11/24/2025

Policy Update: 

November 18, 2025: Converted back to a policy. Minor guidance updates, multiple reference updates and grammatical revisions (AR)

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)
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)

Policy Update:

November 18, 2025: Newly created policy (AR) 

References: 

1. Medicare Managed Care Manual - Chapter 4 - Benefits and Beneficiary Protections Section 10.11 Transplant Services. Issued on 4/22/2016. Accessed via MCM Chapter 4 on 11/04/2025.
2. Transplant Program Application Requirements accessed at Document on 11/04/2025.

Blue Cross Blue Shield of Rhode Island Payment Policy: Transplants - Travel and Accommodations for Medicare Advantage Plans; effective date: 9/1/2022. Viewed on 11/4/2025 

Policy Update: 

November 4, 2025: Annual Review, additional expense exceptions added, minor grammatical changes, disclaimer updated to version with D-SNP plan. (AR)