Ablation, magnetic stimulation and shock wave therapy: 57% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2025 · Medical necessity · age 51–64 Radiofrequency ablation · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for radiofrequency ablation of the right greater saphenous vein.The records document that this patient presents with complaints of edema and heaviness in the right lower…

   The physician reviewer found that a patient has requested authorization and coverage for radiofrequency ablation of the right greater saphenous vein.The records document that this patient presents with complaints of edema and heaviness in the right lower extremity. Medical literature indicates that compression therapy, pharmacologic options, and catheter‑based techniques may be used in managing venous insufficiency and varicose veins. The patient has requested treatment with radiofrequency ablation of the right greater saphenous vein. However, imaging demonstrated that the majority of the right greater saphenous vein is without reflux. Isolated reflux at the saphenofemoral junction is a normal finding based on the location of the first valve. Moreover, treatment with radiofrequency ablation would avoid the saphenofemoral junction to prevent deep vein thrombosis (DVT). As documented, the patient’s current treatment plan would ablate a normal great saphenous vein and is not expected to improve the patient’s symptoms. Applying the guidelines from the Society for Vascular Surgery, the patient does not meet the criteria for treatment with radiofrequency ablation of the right greater saphenous vein. For these reasons, the requested radiofrequency ablation of the right greater saphenous vein is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46369

2. Overturned 2025 · Medical necessity · age 41–50 Radiofrequency ablation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure. In this case, the patient's magnetic resonance imaging (MRI) scan showed minor disc bulges at L4-5 and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure. In this case, the patient's magnetic resonance imaging (MRI) scan showed minor disc bulges at L4-5 and L5-S1 without significant neural compression or advanced facet arthritis. The report also noted the presence of Modic changes and endplate irregularities. Further, a review of the record establishes that the patient’s symptoms are also localized in the lower back without radicular symptoms or sensory/motor deficits. In addition, the record reveals that the patient has attempted conservative modalities without success. Given there is no severe spinal stenosis, instability, or large disc herniation in the setting of a degenerated disc with a decrease in disc height and the presence of Modic changes on MRI, there is good evidence to suggest that the patient’s isolated low back pain is vertebrogenic in origin with good potential for pain relief with the Intracept procedure. As such, the requested Intracept procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46265

3. Overturned 2025 · Medical necessity · age 41–50 Radiofrequency ablation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure. Intracept is a U.S. Food and Drug Administration (FDA)-approved minimally invasive outpatient…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure. Intracept is a U.S. Food and Drug Administration (FDA)-approved minimally invasive outpatient procedure. It is implant-free and preserves spinal integrity by negating the need for extensive tissue exposure and disruption. No restrictions are placed on the patient afterward, and in most cases, pain relief is rapid. It preserves future treatment options for patients with chronic low back pain. In this case, the patient has a history of mixed Modic type I and II changes at L4-5 with chronic low back pain significantly impacting activities of daily living. The patient has attempted treatment of chronic lower back pain with physical therapy and other treatments. The literature supports the use of the Intracept procedure in patients with chronic low back pain with Modic type vertebral changes, such as the patient in this case. All told, the requested Intracept procedure is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46247

4. Overturned 2025 · Medical necessity · age 51–64 Radiofrequency ablation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation of the sacroiliac joint, with imaging guidance. Given the literature findings in support of RFA for sacroiliac pain, the documentation of…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation of the sacroiliac joint, with imaging guidance. Given the literature findings in support of RFA for sacroiliac pain, the documentation of subjective and objective findings consistent with sacroiliac-mediated pain, and the patient’s positive sacroiliac block with pain alleviation, the requested procedure is medically appropriate in this clinical setting. As such, the requested RFA of the sacroiliac joint, with imaging guidance, is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with a subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44754

5. Overturned 2025 · Medical necessity · age 51–64 Radiofrequency ablation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for nerve ablation treatment. In this case, this patient had recently experienced 70% to 80% pain relief from radiofrequency ablation (RFA) for over six months. In…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for nerve ablation treatment. In this case, this patient had recently experienced 70% to 80% pain relief from radiofrequency ablation (RFA) for over six months. In addition, the patient has been treated with NSAIDs, Robaxin, Skelaxin, methocarbamol, baclofen, gabapentin, and physical therapy. Overall, it is medically appropriate to repeat the RFA as it has been found to be safe and effective and will likely decrease the patient’s pain in this clinical setting. As such, the requested nerve ablation treatment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with a subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44630

6. Overturned 2025 · Medical necessity · age 41–50 Radiofrequency ablation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation (RFA) of the right sacroiliac joint. The medical literature supports the use of RFA for this patient’s…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation (RFA) of the right sacroiliac joint. The medical literature supports the use of RFA for this patient’s condition. One publication notes that there is Level III evidence for radiofrequency neurotomy as a treatment option for sacroiliac joint pain. Another study found that, “Using a minimally invasive approach, repeat CRFA [cooled RFA] provided lasting relief of chronic SIJ [sacroiliac joint] pain while reducing patients’ utilization of medical services. Patients’ pain relief was 5.5 months after the first procedure and 9.0 months after the repeat CRFA.” Finally, another group of authors also reported that there is moderate effectiveness of RFA for the treatment of posterior sacroiliac joint pain. Given the literature findings in support of RFA for sacroiliac pain, the documented relief from prior radiofrequency treatment for right sacroiliac-mediated pain, and documentation of subjective and objective findings consistent with returning sacroiliac mediated pain, the requested procedure is indicated for treatment. All told, the requested RFA of the right sacroiliac joint is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44600

7. Overturned 2025 · Medical necessity · age 51–64 Radiofrequency ablation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar and sacral facet joint radiofrequency neurolysis at L3-L4, L4-L5, and L5-S1. In this case, the patient has a history of degenerative disc disease at…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar and sacral facet joint radiofrequency neurolysis at L3-L4, L4-L5, and L5-S1. In this case, the patient has a history of degenerative disc disease at L3-L4, L4-L5, and L5-S1. Further, the record establishes that the patient has had relief with medial branch blocks with greater than 90% improvement. Overall, radiofrequency ablation (RFA) will provide pain relief compared to other options such as medications, conservative care, and continued facet joint injections. As such, the requested lumbar and sacral facet joint radiofrequency neurolysis at L3-L4, L4-L5, and L5-S1 is medically necessary for the treatment of the patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with a subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44441

8. Upheld 2025 · Medical necessity · age 41–50 Radiofrequency ablation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation of the sacroiliac joint. Findings: The physician reviewer found that With regards to the evidence surrounding radiofrequency ablation of…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for radiofrequency ablation of the sacroiliac joint. Findings: The physician reviewer found that With regards to the evidence surrounding radiofrequency ablation of the sacrum, the evidence is mixed. The majority of studies evaluating sacral lateral branch radiofrequency ablation (SLBRFA) utilize single or dual intra-articular blocks for the diagnosis of sacroiliac joint (SIJ) pain. While utilizing dual diagnostic blocks has been suggested to improve the selection of patients who may benefit from radiofrequency ablation, it is still not targeting the nerve that is being ablated, and the utility of this approach has been questioned. A comprehensive review found that medical literature is limited by variability in selection criteria, the specific nerves targeted by radiofrequency ablation, and the types of radiofrequency ablation technology and techniques utilized in clinical outcome studies. A review of medical literature reveals that there are no studies that evaluate multi-site, multi-depth, or any other form of sacral lateral branch blocks to predict success with SLBRFA. Further, the American Society of Pain and Neuroscience (ASPN) guidelines point out the flaws in the design of the studies for sacroiliac joint radiofrequency in that there are multiple ways to approach the diagnostic block, as well as multiple techniques to perform the ablation. Regardless, the guidelines recommend a diagnostic block for the lateral sacral branches prior to performing the radiofrequency ablation. Based on the review of evidence and the lack of diagnostic sacroiliac joint block prior to the requested SLBRFA, the procedure in question is not medically appropriate in this clinical setting. As such, the requested radiofrequency ablation of the sacroiliac joint is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with a subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44408

9. Upheld 2025 · Medical necessity · age 41–50 Radiofrequency ablation · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral radiofrequency ablation. The American Society of Interventional Pain Physicians (ASIPP) guidelines on facet joint interventions note that the evidence…

   Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral radiofrequency ablation. The American Society of Interventional Pain Physicians (ASIPP) guidelines on facet joint interventions note that the evidence is level III, indicating weak-to-moderate strength of recommendation with emerging evidence, for thoracic radiofrequency ablation with the inclusion of one relevant randomized controlled trial and three observational studies. The guidelines further note that the level of evidence is II, indicating moderate strength of recommendation, for thoracic therapeutic facet joint nerve blocks with the inclusion of two randomized controlled trials and one observational study with long-term improvement. Overall, there is a paucity of literature to support the use of thoracic radiofrequency ablation. In addition, while the expectation with radiofrequency ablation is relief for six months, the records indicate that the patient is experiencing only four months of relief with prior radiofrequency ablation. Therefore, bilateral radiofrequency ablation is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-43842

10. Upheld 2025 · Experimental or investigational · age 51–64 Radiofrequency ablation · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for genicular nerve block for the right knee and/or radiofrequency ablation for the right knee. “The evidence supporting the use of…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for genicular nerve block for the right knee and/or radiofrequency ablation for the right knee. “The evidence supporting the use of radiofrequency ablation for the management of knee osteoarthritis is highly uncertain, with modest, short-term benefits that are not sustained. Given the very low certainty of current data, we advise against its routine use until more robust evidence is available.” A systematic review and meta-analysis conclude, `Standardization of techniques and further trials are needed to confirm long-term outcomes.` According to the literature, genicular nerve block and radiofrequency ablation are unlikely to provide long-term benefits. Therefore, the requested genicular nerve block for the right knee and radiofrequency ablation for the right knee are not likely to be more beneficial for the treatment of the patient than any available standard therapy. Findings: Two of the three reviewers found that the requested procedures are not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedures are not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: Reviewer 1 is board-certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Reviewer 2 is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and occupational medicine and is actively practicing. Reviewer 3 is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewers are experts in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case EI25-46213

11. Upheld 2025 · Experimental or investigational · age 21–30 Other · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for cryoneurolysis of a peripheral nerve. Cryoneurolysis is an interventional pain procedure that has limited and evolving evidence regarding its…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for cryoneurolysis of a peripheral nerve. Cryoneurolysis is an interventional pain procedure that has limited and evolving evidence regarding its long-term efficacy and comparative benefit. Current clinical literature does not demonstrate consistent superiority of this treatment over established standard therapies. Standard management for peripheral nerve entrapment syndromes includes conservative measures such as physical therapy, pharmacologic management, transcutaneous electrical nerve stimulation, and, when indicated, targeted injections or surgical intervention. Based on the available evidence, the requested cryoneurolysis is not likely to be more beneficial for the treatment of the patient’s condition than any available standard therapy.Findings:The reviewers found that the requested service is not likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Final Result:The reviewers determined that the requested service is not likely to be more beneficial for the treatment of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewers are board-certified in physical medicine and rehabilitation and anesthesiology with subspecialty certification in pain medicine and are actively practicing. The reviewers are knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case EI25-45866

12. Upheld 2025 · Experimental or investigational · age 31–40 Other · Skin The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for pilonidal cyst laser ablation (Sinus Laser Closure [SiLaC]). Pilonidal disease is a chronic, suppurative condition that…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for pilonidal cyst laser ablation (Sinus Laser Closure [SiLaC]). Pilonidal disease is a chronic, suppurative condition that typically occurs in the sacrococcygeal region and may have periods of inactivity and recurrence. While multiple treatment options exist, newer techniques such as SiLaC are still being evaluated and are not considered standard therapy. Comparative studies have shown that traditional surgical approaches, such as flap closure, demonstrate better healing outcomes than SiLaC. Additional studies comparing laser treatment to excision techniques have reported higher rates of residual disease and recurrence with laser therapy. Overall, current medical literature does not support SiLaC as superior to established surgical treatments. Therefore, the requested pilonidal cyst laser ablation (SiLaC) is not likely to be more beneficial than any available standard therapy for the treatment of this condition.Findings: Two of the three reviewers found that the requested service is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service is not likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: Reviewer 1 is board-certified in general surgery with subspecialty certification in colon and rectal surgery and is actively practicing. Reviewer 2 is board-certified in general surgery with subspecialty certification in colon and rectal surgery and is actively practicing. Reviewer 3 is board-certified in general surgery with subspecialty certification in colon and rectal surgery and is actively practicing. The reviewers are experts in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case EI25-44935