Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Osteolytic Bone Pain
RFA may be considered medically necessary to palliate pain in individuals with osteolytic bone metastases who have failed or are poor candidates for standard treatments such as radiation or opioids.
RFA for osteolytic bony metastases not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore, non- covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Osteoid Osteomas
RFA may be considered medically necessary to treat osteoid osteomas that cannot be managed successfully with medical treatment.
RFA for osteoid osteomas not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Code
