Coverage Criteria for Radiofrequency Ablation Policy

This checklist outlines the coverage criteria and documentation requirements for the Intracept™ Procedure as per Physician’s Health Plan of Northern Indiana. It details the medical necessity criteria, including chronic low back pain duration, MRI findings, and contraindications. Providers must adhere to these guidelines to ensure compliance and proper patient documentation. For further information, refer to the policy effective from 09/15/25.