MEDICAL POLICY – 7.01.565

Ablation of Peripheral Nerves to Treat Pain BCBSA Ref. Policy: 7.01.154

Effective Date: Dec. 1, 2019

Last Revised: Jan. 1, 2020

Replaces: 7.01.154

RELATED MEDICAL POLICIES:

7.01.147 Ablation Procedures for Peripheral Neuromas

7.01.563 Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and

Atypical Facial Pain

7.01.564 Pulsed Radiofrequency

Select a hyperlink below to be directed to that section.

POLICY CRITERIA | CODING | RELATED INFORMATION

EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Peripheral nerves are the nerves that connect the brain and spinal cord to the body. Nerves

transmit sensation, including pain. Newer technqiues to try to treat pain arising from the

peripheral nerves involve trying to destroy a small part of the nerve. The goal is to try to

interrupt pain signals. All techniques to destroy parts of the peripheral nerve, including using

devices that create heat or extreme cold and devices that combine heat and cooled water are

investigational. That means they need more study to see if they are effective.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The

rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for

providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can

be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a

service may be covered.

Policy Coverage Criteria

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Service Investigational Ablative procedures of the

peripheral nerves

Ablative procedures of peripheral nerves to treat pain,

including but not limited to pain associated with plantar

fasciitis or knee osteoarthritis, are considered investigational.

Ablative procedures include, but are not limited to the

following:

• Cooled radiofrequency ablation (eg, COOLIEF)

• Cryoneuroloysis (cryoablation, cryotherapy, cryoanalgesia)

• Radiofrequency ablation (RFA)

Coding

Code Description

CPT 0441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity

distal/peripheral nerve

64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance,

when performed (new code effective 1/1/20)

64640 Destruction by neurolytic agent; other peripheral nerve or branch

64999 Unlisted procedure, nervous system

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS

codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Related Information

N/A

Evidence Review

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Description

Radiofrequency ablation (RFA) and cryoneurolysis of nerves have been proposed as a treatments

for several different types of pain. RFA has been used to treat a number of clinical pain

syndromes such as trigeminal neuralgia as well as cervical and lumbar pain.. This medical policy

evaluates the application of RFA, and cryoneurolysis in peripheral sites distant from the spine.

Background

Plantar Fasciitis

Plantar fasciitis is a common cause of foot pain in adults, characterized by deep pain in the

plantar aspect of the heel, particularly on arising from bed. While the pain may subside with

activity, in some patients the pain may persist, impairing activities of daily living. On physical

examination, firm pressure will elicit a tender spot over the medial tubercle of the calcaneus. The

exact etiology of plantar fasciitis is unclear, although repetitive injury is suspected. Heel spurs

are a common associated finding, although it has never been proven that heel spurs cause the

pain. Asymptomatic heel spurs can be found in up to 10% of the population.

Treatment

Most cases of plantar fasciitis are treated with conservative therapy, including rest or

minimization of running and jumping, heel cups, and nonsteroidal anti-inflammatory drugs.

Local steroid injection may also be used. Improvement may take up to 1 year in some cases.

Cryoneurolysis uses cold (freezing) for the treatment of plantar fasciitis for those who have failed

prior conservative therapy. The most important aspect of this treatment modality is locating the

exact area of heel pain. The target area for the tip of the cryoprobe is the area where there is the

greatest pain. The cyroneurolysis procedure provides ablation of the divisional branches of the

medial calcaneal nerve medially and the branches of the lateral calcaneal nerve laterally. Ablative

procedures to include radiofrequency ablation and cryoneuroloysis (cryoablation, cryoanalgesia,

cryotherapy) have been proposed as an alternative for the treatment of chronic heel pain

associated with plantar fasciitis.

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Knee Osteoarthritis

Knee osteoarthritis is common, costly, and a cause of substantial disability. Among U.S. adults,

the most common causes of disability are arthritis and rheumatic disorders.

Treatment

Treatment for osteoarthritis of the knee aims to alleviate pain and improve function. However,

most treatments do not modify the natural history or progression of osteoarthritis and are not

considered curative. Nonsurgical modalities that are used include exercise; weight loss; various

supportive devices; acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as

ibuprofen; nutritional supplements (glucosamine, chondroitin); and intra-articular

viscosupplements. Corticosteroid injection may be considered when relief from nonsteroidal

anti-inflammatory drugs is insufficient or the patient is at risk from gastrointestinal adverse

effects. If symptom relief is inadequate with conservative measures, invasive treatments may be

considered. Operative treatments for symptomatic OA of the knee include total joint

arthroplasty.

When an individual exhibits knee pain, the pain signals can be generated from the peripheral

nerves innervating the knee. The nerves supplying the knee are called the genicular nerves,

comprising the articular branches of the obturator, femoral, saphenous, common peroneal, and

tibial nerves. An ablative procedure such as radiofrequency ablation, cryoneurolysis and

chemical neurolysis of any of these genicular nerves may be performed to restore function and

alleviate knee pain as an alternative therapy. These ablative procedures have been proposed as

an alterative when other measures have not effectively managed the treatment of chronic knee

pain.

Nerve Radiofrequency Ablation

Nerve radiofrequency ablation (RFA) is a minimally invasive method that involves the use of heat

and coagulation necrosis to destroy nerve tissue. A needle electrode is inserted through the skin

and into the tissue around the nerve to be ablated. A high-frequency electrical current is applied

to the target tissue and a small sphere of tissue is coagulated around the needle by the heat

generated. It is theorized that the thermal lesioning of the nerve destroys peripheral sensory

nerve endings, resulting in the alleviation of pain. Cooled radiofrequency (RF) treatment is a

variation of nerve RFA using a water-cooled probe that applies more energy at the desired

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location without excessive heat diffusing beyond the area, causing less tissue damage away

from the nerve (see Table 1). The goal of ablating the nerve is the same.

Nerve RFA is also distinguished from pulsed RF treatment, which has been investigated for

different types of pain. The mechanism of action of pulsed RF treatment is uncertain, but it is

thought not to destroy the nerve.1 If it does produce some degree of nerve destruction, it is

thought to cause less damage than standard RFA. Some studies refer to pulsed RF treatment as

ablation.

For the indications assessed in this medical policy, nerve RFA should be distinguished from RF

energy applied to areas other than the nerve to cause tissue damage. Some patients have been

treated for plantar fasciitis with a fasciotomy procedure using an RF device. This procedure does

not ablate a specific nerve.

Table 1. Types of Radiofrequency Ablation

Type Procedure Tissue

Temperature

Key Differences

Standard RFA Electrode tip provides

thermal energy for 90 – 130

seconds

70 – 90â C Longer lasting but with more adjacent

thermal tissue injury and limitation in size

and shape of lesion.

Pulsed RFA Non-ablative - provides 20

ms pulses every 30 seconds

42â C Limits tissue damage but results in

incomplete and transient pain relief

Cooled RFA Water circulates through RF

electrode to cool the tip

60â C Larger lesion with limited thermal injury

to tissue. Less complete and shorter

durability than standard RFA

RF: radiofrequency; RFA: radiofrequency ablation

Adapted from Oladeji et al (2019)2

Cooled Radiofrequency (C-RFA)

Cooled radiofrequency is a minimally invasive method in which a radiofrequency generator

transmits a small current of thermal radiofrequency energy through an insulated, water-cooled,

electrode or probe placed within tissue to target the sensory nerves responsible for sending

pain signals. Coolief™ (Avanos previously known as Haylard Health) circulates water through the

device while heating nervous tissue to create a larger treatment area than conventional

radiofrequency is able to treat. “This combination of ionic heating, produced by the friction of

Page | 6 of 12 ∞

charged water molecules, and cooling deactivates the nerves responsible for sending pain

signals to the brain by targeting the pain-transmitting nerves without excessive heating, leading

to pain relief.”25 Coolief™ is performed in an outpatient setting.

Cryoneurolysis

Cryoneuroloysis also referred to as cryoablation, cryotherapy or cryoanalgesia temporarily

blocks nerve conduction along peripheral pathways using a small probe to freeze the target

nerve and treat a variety of painful conditions. Cryoneurololysis treatments that use nitrous

oxide (boiling point of -88.5⁰ C) as the coolant are reversible. Nerves treated in this temperature

range experience a disruption of the axon, with Wallerian degeneration occurring distal to the

site of injury. The axon and myelin sheath are affected, but the connective tissues remain intact.

The axon can regenerate along the nerve path, usally at the rate of 1-2 mm per day. Thus, the

nerve basically dies as it freezes, which stops the pain signals from transmitting. However, over

time the nerve regrows, which may mean recurrence of the pain. Cryoneurolysis differs from

cyroablation in that cryoablation treatments use liquid nitrogen (boiling point of -195.8⁰ C) as

the coolant. Treatments of the nerve in this temperature range are irrervsible as the nerves

experience a disruption of both the axon and the endoneurium connective tissue layer. These

treatments are being investigated to alleviate pain in knee OA and to manage pain following

total knee arthroplasty. The iovera° cryoablation system is a portable handheld device that

applies percutaneous and targeted delivery of cold to superficial peripheral nerves.

Summary of Evidence

For individuals who have plantar fasciitis who receive radiofrequency ablation (RFA) of

peripheral nerves for the treatment of chronic heel pain associated with plantar fasciitis, the

evidence includes two randomized controlled trials (RCTs). The relevant outcomes include

symptoms and functional outcomes, and quality of life (QOL). One of the randomized trials only

evaluated 17 patients, and assessment of randomized outcomes was limited to 4 weeks

posttreatment. A second RCT evaluated 36 patients out to 12 weeks. The case series generally

had small sample sizes, and many had methodologic deficiencies such as retrospective

assessment of pain. To be more confident in the efficacy of this treatment, controlled trials with

larger samples and longer follow-up would be necessary. The evidence is insufficient to

determine the effects of the technology on health outcomes.

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For individuals who have knee osteoarthritis (OA) who receive radiofrequency ablation (RFA) of

peripheral nerves, such as the genicular nerves, comprising the articular branches of the

obturator, femoral, saphenous, common peroneal, and tibial nerves, the evidence includes

includes 2 RCTs with a total of 211 patients with a 6-month follow-up and observational studies

with 12 months of follow-up. The relevant outcomes include symptoms, functional outcomes,

and quality of life (QOL). Knee OA is a common disorder in older adults. RFA of the genicular

nerves has the potential to alleviate pain and improve function in this population, and might

also delay or eliminate the need for TKA. To date, the evidence on RFA for knee pain includes 2

RCTs with a total of 211 patients with a 6-month follow-up and prospective observational

studies with 12 months of follow-up. The larger of the RCTs compared C-RFA to active control of

steroid injection and utilized genicular nerve blocks to select patients for the study. At 1 month

after treatment, pain scores on an 11-point numeric rating score (NRS) differed by less than 1

point, a finding that was statistically significant but of marginal clinical significance. By three

months after treatment pain scores had increased in the steroid group, consistent with the

known durability of the treatment. Pain scores in the RFA group remained low in patients who

remained in the study. Durability of this treatment approach to 1 year has been evaluated in a

follow-up to the RCT, a retrospective study, and a small (n=25) independent prospective study.

In both of the industry-sponsored publications, 65% of the patients treated with C-RFA reported

a greater than 50% reduction in pain scores at 12 months. In an independent and prospective

observational study, about one-third continued to show a response at one year after RFA of the

genicular nerves. The second RCT used stimulation to identify the genicular nerves, rather than

genicular nerve blocks with an anesthetic. None of the studies were blinded, which may have

biased the subjective outcome measures. It should be noted that the anatomy of the genicular

nerves is variable, and the best method for their identification has not been determined. Study

in a larger number of patients, preferably in blinded studies with active control and follow-up

longer than 12 months, is needed to determine the benefits and potential harms of this

treatment. The evidence is insufficient to determine the effects of the technology on health

outcomes.

For individuals who have knee osteoarthritis who received cooled radiofrequency, some studies

may have shown promising results, however, there were concerns about procedural protocols,

study quality, small study sizes and patient follow-up which limit the applicability of any specific

study to clinical practice. Further randomized clinical trials (RCTs) are needed to determine the

efficacy of cooled radiofrequency to include studies with larger sample sizes, longer follow up

periods and double-blinding to establish the overall effectiveness of these procedures and to

compare their outcomes against one another. The evidence is insufficient to determine the

effects of this technology on net health outcomes.

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For individuals who have knee osteoarthritis or total knee arthroplasty (TKA) who received

cryoneuroloysis (cryoablation, cryoanalgesia, cryotherapy) of peripheral nerves, the evidence

includes an RCT with 180 patients and a retrospective comparative study. The relevant outcomes

include symptoms, functional outcomes, and QOL. Cryoneurolysis in patients with knee OA

resulted in a greater decrease in the Western Ontario McMaster Universities Osteoarthritis Index

(WOMAC) pain score, WOMAC total score, and visual analog scale (VAS) score at 30 days

compared with sham-treated controls. However, subsequent measurements showed no

significant benefit of cryoneurolysis on WOMAC score at 60 days or VAS scores at 60 or 90 days.

Perioperative cryoneurolysis was shown in a retrospective comparison to reduce the length of

stay and opioid use in patients undergoing TKA. These results need to be confirmed in an RCT.

Several technical issues including the optimal number of applications for each nerve, the

duration of treatment, and the duration of thawing before moving the cannula have not been

resolved. The most effective method for determining probe insertion location (eg, ultrasound-

guided or based on anatomic landmarks) also need to be established. The evidence is

insufficient to determine the effects of the technology on health outcomes.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in

Table 2.

Table 2. Summary of Key Trials

NCT No. Trial Name Planned

Enrollment

Completion

Date

Ongoing

NCT03628482a A Randomized Controlled Study to Compare Efficacy of

Continuous Versus Pulsed Radiofrequency Treatment of

Genicular Nerves to Alleviate Pain and Improve Functional

Impairment in Patients With Advanced Osteoarthritis of the

Knee

188 Aug 2019

NCT03381248 A Prospective, Multi-center, Randomized, Clinical Trial

Evaluating the Safety and Effectiveness of Using COOLIEF™

Cooled Radiofrequency Probe to Create Lesions of the

Genicular Nerves and Comparing a Single Injection of

Hyaluronic Acid in the Management of Knee Pain

168 Oct 2019

https://www.clinicaltrials.gov/ct2/show/NCT03628482?term=NCT03628482&rank=1https://www.clinicaltrials.gov/ct2/show/NCT03381248?term=NCT03381248&rank=1

Page | 9 of 12 ∞

NCT No. Trial Name Planned

Enrollment

Completion

Date

NCT02925442 Comparison Between Cooled (C-RFA) and Standard (t-RFA)

Radiofrequency Ablation, and Control for Pain

Management Following Unilateral Knee Arthroplasty: A

Double-Blinded, Parallel-Grouped, Placebo-Controlled

Randomized Clinical Trial

150 Feb 2020

NCT02915120 Ultrasound-Guided Pulsed Radiofrequency Of The

Genicular Nerves In The Treatment Of Patients With

Osteoarthritis Knee Pain: Randomized, Double-Blind,

Placebo-Controlled Trial

142 Dec 2020

Unpublished

NCT02294864 A Controlled Comparison of Pulsed Radiofrequency Vs

Physical Therapy on Treating Chronic Knee Osteoarthritis

50 Apr 2017

(unknown)

NCT02260869 Efficacy of Cooled and Monopolar Radiofrequency Ablation

of the Geniculate Nerves for the Treatment of Chronic

Osteoarthritic Knee Pain

78 Jun 2019

(completed)

NCT: national clinical trial

NR: not reported

Practice Guidelines and Position Statements

The American College of Foot and Ankle Surgeons

The American College of Foot and Ankle Surgeons (2018) issued consensus guidelines on the

treatment of acquired infracalcaneal heel pain.21 The safety and efficacy of bipolar

radiofrequency were listed as uncertain (neither appropriate nor inappropriate).

Medicare National Coverage

There is no national coverage determination.

Regulatory Status

A number of radiofrequency (RF) generators and probes have been cleared for marketing by the

U.S. Food and Drug Administration (FDA) through the 510(k) process. In 2005, the SInergy®

https://www.clinicaltrials.gov/ct2/show/NCT02925442?term=NCT02925442&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02915120?term=NCT02915120&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02294864?term=NCT02294864&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02260869?term=NCT02260869&rank=1

Page | 10 of 12 ∞

(Kimberly-Clark/Baylis), a water-cooled single-use probe, was cleared by the FDA, listing the

Baylis Pain Management Probe as a predicate device. The intended use is withan RF generator

to create RF lesions in nervous tissue. FDA product code: GXD.

In 2011, NeuroTherm® NT 2000 (NeuroTherm) was cleared for marketing by the FDA through

the 510(k) process. The FDA determined that this device was substantially equivalent to existing

devices for use in lesioning neural tissue. Existing predicate devices included the NeuroTherm

NT 1000, Stryker Multi-Gen, and Cosman G4 RF Generator.

In 2013, the Cryo-Touch IV (iovera°; Myoscience) was cleared for marketing by the FDA through

the 510(k) process (K123516). Predicate devices were the Cryo-Touch II (K102021) and Cryo-

Touch III (K120415).

In 2017, the COOLIEF Cooled Radiofrequency Probe (Avanos, previously known as Halyard

Health) was cleared for marketing by the FDA through the 510(k) process to be used in

conjunction with a radiofrequency generator to create lesions in nervous tissue (K163461). "The

device is also indicated 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 radiologically-confirmed osteoarthritis (grade 2-

4) and a positive response (> 50% reduction in pain) to a diagnostic genicular nerve block." FDA

Product Code: GXI

References

1. Chua NH, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and

potential indications-a review. Acta Neurochir (Wien). Apr 2011;153(4):763-771. PMID 21116663

2. Oladeji LO, Cook JL. Cooled Radio Frequency Ablation for the Treatment of Osteoarthritis-Related Knee Pain: Evidence,

Indications, and Outcomes. J Knee Surg, 2018 Nov 6;32(1). PMID 30396206

3. Jamison DE, Cohen SP. Radiofrequency techniques to treat chronic knee pain: a comprehensive review of anatomy,

effectiveness, treatment parameters, and patient selection. J Pain Res, 2018 Oct 3;11:1879-1888. PMID 30271194

4. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind

randomized controlled trial. Pain. Mar 2011;152(3):481-487. PMID 21055873

5. Sari S, Aydin ON, Turan Y, et al. Which one is more effective for the clinical treatment of chronic pain in knee osteoarthritis:

radiofrequency neurotomy of the genicular nerves or intra-articular injection?. Int J Rheum Dis, 2016 Aug 16;21(10). PMID

27515095

6. Davis T, Loudermilk E, DePalma M, et al. Prospective, multicenter, randomized, crossover clinical trial comparing the safety and

effectiveness of cooled radiofrequency ablation with corticosteroid injection in the management of knee pain from

osteoarthritis. Reg Anesth Pain Med. Jan 2018;43(1):84-91. PMID 29095245

Page | 11 of 12 ∞

7. El-Hakeim EH, Elawamy A, Kamel EZ, et al. Fluoroscopic Guided Radiofrequency of Genicular Nerves for Pain Alleviation in

Chronic Knee Osteoarthritis: A Single-Blind Randomized Controlled Trial. Pain Physician, 2018 Mar 23;21(2). PMID 29565947

8. McCormick ZL, Reddy R, Korn M, et al. A Prospective Randomized Trial of Prognostic Genicular Nerve Blocks to Determine the

Predictive Value for the Outcome of Cooled Radiofrequency Ablation for Chronic Knee Pain Due to Osteoarthritis. Pain Med,

2018 Jan 5;19(8). PMID 29300971

9. Santana Pineda MM, Vanlinthout LE, Moreno Martin A, et al. Analgesic effect and functional improvement caused by

radiofrequency treatment of genicular nerves in patients with advanced osteoarthritis of the knee until 1 year following

treatment. Reg Anesth Pain Med. Jan/Feb 2017;42(1):62-68. PMID 27875368

10. Davis, TT, Loudermilk, EE, DePalma, MM. Twelve-month analgesia and rescue, by cooled radiofrequency ablation treatment of

osteoarthritic knee pain: results from a prospective, multicenter, randomized, cross-over trial. Reg Anesth Pain Med, 2019 Feb

18. PMID 30772821

11. Kapural, L. Long-term retrospective assessment of clinical efficacy of radiofrequency ablation of the knee using a cooled RF

system. Pain Physician (in press).

12. Radnovich R, Scott D, Patel AT, et. al. Cryoneurolysis to treat the pain and symptoms of knee osteoarthritis: a multicenter,

randomized, double-blind, sham-controlled trial. Osteoarthritis and Cartilage 25 (2017) 1247-1256. PMID 28336454

13. Dasa V, Lensing G, Parsons M. et. al. Percutaneous freezing of sensory nerves prior to total knee arthroplasty. The Knee 23 2016

523-528

14. Gabriel RA, Ilfeld BM. Novel methodologies in regional anesthesia for knee arthroplasty. Anesthesiol Clin. Sep 2018;36(3):387-

401. PMID 30092936

15. Wu YT, Chang CY, Chou YC, et al. Ultrasound-guided pulsed radiofrequency stimulation of posterior tibial nerve: a potential

novel intervention for recalcitrant plantar fasciitis. Arch Phys Med Rehabil. May 2017;98(5):964-970. PMID 28209507

16. Landsman AS, Catanese DJ, Wiener SN, et al. A prospective, randomized, double-blinded study with crossover to determine the

efficacy of radio-frequency nerve ablation for the treatment of heel pain. J Am Podiatr Med Assoc. Jan-Feb 2013;103(1):8-15.

PMID 23328847

17. Cozzarelli J, Sollitto RJ, Thapar J, et al. A 12-year long-term retrospective analysis of the use of radiofrequency nerve ablation for

the treatment of neurogenic heel pain. Foot Ankle Spec. Dec 2010;3(6):338-346. PMID 20817845

18. Cione JA, Cozzarelli J, Mullin CJ. A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the

medial calcaneal nerve and its terminal branches in chronic heel pain. J Foot Ankle Surg. Mar-Apr 2009;48(2):142-147. PMID

19232965

19. iovera° system (Myoscience, Inc)

20. COOLIEF (Halyard Health, Inc)

21. Schneider HP, Baca JM, Carpenter BB, et al. American College of Foot and Ankle Surgeons clinical consensus statement:

diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. Mar-Apr 2018;57(2):370-381. PMID

29284574

History

Date Comments 08/01/18 New policy, approved July 10, 2018. This policy is replacing policy 7.01.154. Policy

created with literature review through June 2018. Ablative procedures of peripheral

Page | 12 of 12 ∞

Date Comments nerves to treat pain for all indications, including but not limited to pain associated with

plantar fasciitis or knee osteoarthritis, is considered investigational for the following

treatments: cooled raddiofrequency ablation (such as, but not limited to

COOLIEF),cryoneuroloysis (cryoablation, cryotherapy, cryoanalgesia), or radiofrequency

ablation (RFA).

12/01/19 Annual Review, approved November 6, 2019. Policy updated with literature review

through July 2019; references added. Title changed to “Ablation of Peripheral Nerves

to Treat Pain” from “Ablative Procedures of Peripheral Nerves to Treat Pain”. Policy

statements unchanged except for minor edits only.

01/01/20 Coding update, added CPT code 64624 (new code effective 1/1/20).

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አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።

( ةالعربي :(. امةھ ماتولعم اإلشعار ھذا يحوي

خالل من ھاعلي صولحلا تريد لتيا التغطيةلل أو ةصحيلاكطيتتغ لىع اظلحفل نةعيم يخراوت في إجراء خاذتال تحتاج وقد .اإلشعار ھذا في

تكلفة أية بدتك دون بلغتك مساعدةوال تاوملالمع ھذه على ولحصال لك يحق .800-722-1471 (TTY: 800-842-5357)

أو طلبك وصخصب مةمھ ماتوعلم عارشإلا ھذا ويحي قدةمھم يخراوت ھناك تكون قد .Premera Blue Cross

اعدةمس تصلايفكالتال دفع فيبـ

.

Arabic

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.

Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez le 800-722-1471 (TTY: 800-842-5357).

Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357).

Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357).

Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357).

Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).

Italiano ( ):Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).

Italian

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期

之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母

語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。

037338 (07-2016)

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@Premera.com

日本語 (Japanese):この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付をご確認くだ

さい。健康保険や有料サポートを維持するには、特定の期日までに行動を

取らなければならない場合があります。ご希望の言語による情報とサポー

トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນີ້. ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົດ ເວລາສະເພາະເພື່ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລື່ອງ າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນີ້ ແລະ ຄວາມຊ່ວຍເຫຼື ອເປັ ນພາສາ ຂອງທ່ານໂດຍບ່ໍ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357).

ູຂໍ້

່

ສໍ ັ

ຈ

ໝ

ສິ

ັ

່

ວ

ຄ

ມ

ມູຮັ

ູມີ ມຂໍ້

ភាសាែខមរ ( ): ឹ

រងរបស់

Premera Blue Cross ។ របែហលជាមាន កាលបរ ិ ឆ ំខានេនៅកងេសចក

េសចកតជី ូ

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់

នដំ ងេនះមានព័ ី

តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ណ ត៌មានយ៉ា ំ ់ តងសខាន។ េសចក

េចទស ់ ន ុ ត

ណងេនះ។ អ វការបេញញសមតភាព ដលកណតៃថ ចបាស

កតាមរយៈ

ដំ ឹ នករបែហលជារតូ ច ថ ់ ំ ់ ងជាក់ ់

នដ

ន

ី ន

ូ

អ

ូ

ជ

ជ

ំណឹងេនះរបែហល

នានា េដើ ីនងរកសាទុ ៉ បរងស់ ុ ់ ក ឬរបាក់ ំ

អ

មប ឹ កការធានារា ខភាពរបស ជ

ធនកមានសិ ទទលព័ មានេនះ និ ំ យេនៅកុងភាសារបសទិ ួ ត៌ ងជ ននួ

ន

់ កេដាយម

អ

នអ

យេចញៃថល។ ួ

នអស

ន

ិ

លុ ើ ូ ូយេឡយ។ សមទ ទ រស័ព 800-722-1471 (TTY: 800-842-5357)។

Khmer

ਕਵਰਜ ਅਤ ਅਰਜੀ ਬਾਰ ਮਹ ਤਵਪਰਨ ਜਾਣਕਾਰੀ ਹ ਸਕਦੀ ਹ . ਇਸ ਨ ਿਜਸ ਜਵਚ ਖਾਸ

ਤਾਰੀਖਾ ਹ ਸਕਦੀਆ ਹਨ. ਜੇਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚ ਮਦਦ ਦ ੇਇਛ ੁਕ ਹ ਤਾਂ ਤਹਾਨ ਅ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ ਝ ਖਾਸ ਕਦਮ ਚ ਕਣ ਦੀ ਲੜ ਹ ਸਕਦੀ ਹ ,ਤਹੁਾਨ ਮਫ਼ਤ ਿਵਚ ਤ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਚ ਜਾਣਕਾਰੀ ਅਤ ਮਦਦ ਪਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).

ਪ ਜਾਬੀ (Punjabi): ਇਸ ਨ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ. ਇਸ ਨ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ

ੰ

ੰ

ੇ ੇ ੇ ੱ ੂ ੋ ੈ ੋੋ ਂ ੁ ੇ ੱ ੋ ੇ ੱੱ ੁ ੱ ੂੁ ੱ ੇ ੱ ੇ ੍ਰ ੈ

ੋ ੰ ੂ ੱ ੁ ੋ ੋ ੈ ੰ

ੋ ੈ ੋ

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين. ميباشد ھمم اطالعات یوحا يهمالعا اين

در ھمم ھای خيتار به باشد.پ رایبستاکنممماش زينهھ اختدپر در مککيا تان بيمهوشش حقظ

Premera Blue Cross طريق از ماش مهبيوشش يا و تقاضا ای پ. يدماين جهتو يهمالعا اين

حق شما. يدشاب داشته اجتياح صیاخ کارھای امانج برای صیمشخ ایھ خيتار به تان، انیمدر ھای کسب برای .نماييد دريافت گانيرا ورط به ودخ زبان به را کمک و اطالعات اين که داريد را اين

استم ) 5357-842-800 مارهباش ماست TTY انکاربر(800-722-1471 مارهش با اطالعات .اييدنم برقرار

้

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może

zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357).

Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter e sta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357).

Español ( ): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este

tiene derecho a recibir esta información y ayuda en su idioma sin costo

aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted

alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

Spanish

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).

ไทย (Thai): ประกาศนมขอมลสาคญ ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน สขภาพของคณผาน Premera Blue Cross และอาจมกาหนดการในประกาศน คณอาจจะตอง ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท มคาใชจาย คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่มคาใชจาย โทร 800-722-1471 (TTY: 800-842-5357)

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Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).