MEDICAL POLICY – 7.01.564

Pulsed Radiofrequency

Effective Date: Oct. 1, 2019

Last Revised: Sept. 5, 2019

Replaces: N/A

RELATED MEDICAL POLICIES:

7.01.147 Ablation Procedures for Peripheral Neuromas

7.01.555 Facet Joint Denervation

7.01.565 Ablative Procedures of Peripheral Nerves to Treat Pain

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POLICY CRITERIA | CODING | RELATED INFORMATION

EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Radiofrequency ablation is a way of destroying part of nerves to treat pain. An electrical current

is produced by radio waves. The current is applied to a small area of nerve tissue, thus

destroying (ablating) part of the nerve and interrupting pain signals. Pulsed radiofrequency is

similar to radiofrequency ablation in that it is still being studied. Instead of a constant current

being applied, pulsed radiofrequency calls for short bursts of energy. These intermittent bursts

of energy allow more electrical current to be applied while keeping temperatures below the

range that would ablate the nerve. Pulsed radiofrequency is investigational (unproven) to treat

pain. More, larger, and longer studies are needed to see if this technique is safe and 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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Procedure Investigational Pulsed radiofrequency Pulsed radiofrequency for the treatment of various chronic

pain syndromes is considered investigational, including but

not limited to the following:

• Chronic facial and head pain (persistent idiopathic facial pain

(PIFP)/spheno-palatine ganglion)

• Coccydynia

• Complex regional pain syndrome (reflex sympathetic

dystrophy)

• Diabetic peripheral neuropathy

• Discogenic pain

• Facet joint pain (cervical, lumbar, thoracic, sacro-iliac)/

zygapophyseal joint pain

• Headaches (eg, cervicogenic, migraines, cluster, tension)

• Inguinal neuralgia

• Intercostal neuralgia (post-surgical thoracic pain)

• Low back pain

• Lumbo-sacral radicular pain (eg, dorsal root ganglion)

• Meralgia paresthetica (burning pain in the outer thigh related

to lateral femoral cutaneous nerve entrapment)

• Metacarpal or metatarsal joint pain of the hands and feet

• Morton’s neuroma

• Myofascial pain syndrome

• Neck pain

• Occipital neuralgia

• Ophthalmic neuralgia

• Orchialgia (testicular pain/spermatic cord)

• Osteoarthritis of the knee or hip

• Pelvic pain (eg, superior hypogastric plexus treatment for

interstitial cystitis)

• Peripheral neuromas

• Piriformis syndrome (buttock pain and/or pain in the back of

the lower extremity related to sciatic nerve irritation)

• Plantar fasciitis

• Post herpetic neuralgia (ophthalmic neuralgia)

• Pudendal neuralgia

• Sacro-iliac joint pain

• Shoulder pain (suprascapular nerve)

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Procedure Investigational • Tarsal tunnel syndrome (compression neuropathy from

entrapment of the posterior tibial nerve)

• Trigeminal neuralgia

• Vulvodynia

Coding

Code Description

CPT 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

Description

Pulsed radiofrequency (PRF) is a non- or minimally neurodestructive technique, where short

bursts of radiofrequency energy are applied to nervous tissue to treat various chronic pain

syndromes. It is seen as an alternative to continuous (non-pulsed) radiofrequency ablation, as it

is theorized to have significantly less complications or side effects. Its exact mechanism of action

is unclear.

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Background

Pulsed radiofrequency was first used in 1996 as a less destructive alternative to continuous (non-

pulsed) radiofrequency. Pulsed radiofrequency is delivered in short bursts, twice per second,

followed by a quiet phase in which no current is applied. This allows for cooling of the electrode

keeping it below the neurodestructive threshold of 45° C. Pulsing the radiofrequency current

allows the power output of the generator to be greatly increased, allowing for far stronger

electrical fields than in continuous radiofrequency. For example, the voltage output is usually 15-

25 volts for the continuous mode radiofrequency. The pulsed radiofrequency output is 45 volts.

As a result, higher voltages can be applied in pulsed radiofrequency. Because the average

temperature near the pulsed radiofrequency electrode does not reach the neurodestructive

range, the risk of destroying nearby tissue is reduced.

Pulsed radiofrequency has been used in the treatment of peripheral neuropathies, arthrogenic

pain, painful trigger points, radiculopathy, and many other chronic pain syndromes. Unlike the

known side effects of continuous radiofrequency such as, neuritis-like reactions, motor deficits,

and the risk of deafferentation pain syndrome, pulsed radiofrequency seems to have few side

effects and is seen as relatively safe. However, even though there is much anecdotal evidence

which favors the use of pulsed radiofrequency for the use of pain relief without nervous tissue

damage, especially in the treatment of neuropathic pain, there is a lack of randomized

controlled trials (RCTs) substantiating its efficacy. The evidence is insufficient to determine the

effects of the technology on health outcomes.

Summary of Evidence

For individuals with various chronic pain syndromes, especially neuropathic pain who received

pulsed radiofrequency, the evidence includes a small number of RCTs, non-randomized

controlled trials, prospective uncontrolled trials, retrospective studies, case series, and case

reports. The majority of the uncontrolled and observational studies reported clinical efficacy of

pulsed radiofrequency, however many of these studies had limitations. The controlled clinical

data is limited and with inconsistent findings. Further research in the clinical and biological

effects of pulsed radiofrequency is needed including well-designed, randomized controlled

clinical trials with a large sample size and long-term follow-up to determine the therapeutic

effect and safety of this treatment modality. There is also a lack of data comparing pulsed

radiofrequency with conventional treatments. As such, it is unknown if pulsed radiofrequency

offers any treatment advantage over other conventional treatments. The evidence is insufficient

to determine the effects of the technology on health outcomes.

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Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 1.

Table 1. Summary of Key Clinical Trials

NCT No. Trial Name Planned

Enrollment

Completion

Date

Ongoing

NCT03567590 The Efficacy and Safety of Sphenopalatine Ganglion

Pulsed Radiofrequency Treatment for Cluster Headache

80 May 2021

NCT02915120 Ultrasound-Guided Pulsed Radiofrequency in the

Treatment of Patients with Osteoarthritis Knee

142 Dec 2020

NCT03228316 Superior Hypogastric Plexus Block Versus Pulsed

Radiofrequency for Chronic Pelvic Cancer Pain

40 Not yet recruiting,

Estimated start

date Oct 2019

NCT: national clinical trial

Practice Guidelines and Position Statements

American Society of Interventional Pain Physicians

The American Society of Interventional Pain Physicians (ASIPP) published an updated guideline

on interventional techniques in the management of chronic spinal pain Part II guidance and

recommendation which states the following:

• Lumbar spine

o The evidence for therapeutic facet joint interventions is good for conventional

radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint

nerve blocks, and limited for intraarticular injections

o For sacroiliac interventions, the evidence for cooled radiofrequency neurotomy is fair;

limited for intraarticular injections and periarticular injections; and limited for both

pulsed radiofrequency and conventional radiofrequency neurotomy

https://clinicaltrials.gov/ct2/show/NCT03567590?term=NCT03567590&rank=1https://clinicaltrials.gov/ct2/show/NCT02915120?term=NCT02915120&rank=1https://clinicaltrials.gov/ct2/show/NCT03228316?term=NCT03228316&rank=1

Page | 6 of 11 ∞

• Cervical Spine

o Evidence for therapeutic facet joint intervention is fair for conventional cervical

radiofrequency neurotomy

• Thoracic Spine

o Evidence is limited for radiofrequency neurotomy

Medicare National Coverage

There is no national coverage determination.

Regulatory Status

A number of radiofrequency generators and probes have been cleared for marketing through

the U.S. Food and Drug Administration (FDA) 510(k) process.

References

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PMID:14731381.

3. Akbas M, Gunduz E, Sanli S, Yegin A. Sphenopalatine ganglion pulsed radiofrequency treatment in patients suffering from

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6. Bayer E, Racz GB, Miles D, Heavner J. Sphenopalatine ganglion pulsed radiofrequency treatment in 30 patients suffering from

chronic face and head pain. Pain Pract. 2005;5(3):223-227.

7. •Bhatjiwale MG, Bhatjiwale MM, Bhagat A. Ultra-extended euthermic pulsed radiofrequency for the treatment of ophthalmic

neuralgia: A case report with elaboration of a new technique. Surg Neurol Int. 2016;7(Suppl 35): S818-S823. PMID 27990312

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Page | 7 of 11 ∞

9. Bui C, Pangarkar S, Zeitlin SI. Relief of urinary urgency, hesitancy, and male pelvic pain with pulse radiofrequency ablation of the

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16. Chon JY, Hahn YJ, Sung CH, et al. Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: Two case

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18. Cohen SP, Sireci A, Wu CL, et al. Pulsed radiofrequency of the dorsal root ganglia is superior to pharmacotherapy or pulsed

radiofrequency of the intercostal nerves in the treatment of chronic postsurgical thoracic pain. Pain Physician. 2006;9(3):227-

235.PMID:16886031.

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20. Deniz S, Purtuloglu T, Tekindur S, et al. Ultrasound-guided pulsed radiofrequency treatment in Morton's neuroma. J Am Podiatr

Med Assoc. 2015;105(4):302-306.PMID:25945935.

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of idiopathic trigeminal neuralgia. Eur J Pain. 2007;11(3):309-313.PMID:16762570.

23. Eyigor C, Eyigor S, Akdeniz S, Uyar M. Effects of intra-articular application of pulsed radiofrequency on pain, functioning and

quality of life in patients with advanced knee osteoarthritis. J Back Musculoskelet Rehabil. 2015;28(1):129-134.PMID:25061031.

24. Facchini G, Spinnato P, Guglielmi G, et al. A comprehensive review of pulsed radiofrequency in the treatment of pain associated

with different spinal conditions. Br J Radiol. 2017;90(1073): 20150406.PMID:28186832.

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27. Gallagher RM. Pulsed radiofrequency treatment: What is the evidence of its effectiveness and should it be used in clinical

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28. Gofeld M, Restrepo-Garces CE, Theodore BR et al. Pulsed radiofrequency of suprascapular nerve for chronic shoulder pain: a

randomized double-blind active placebo-controlled study. Pain Pract. 2013;13(2):96-103. PMID:22554345.

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Page | 8 of 11 ∞

30. Guo J, Dong X, Zhao X. Treatment of trigeminal neuralgia by radiofrequency of the Gasserian ganglion. Rev Neurosci.

2016;27(7):739-743.PMID:27383870.

31. Guo L, Kubat NJ, Nelson TR et al. Meta-analysis of clinical efficacy of pulsed radiofrequency energy treatment. Ann Surg. 2012

Mar; 255(3):457-67 PMID: 22301609.

32. Gupta A, Huettner DP, Dukewich M. Comparative effectiveness review of cooled Versus pulsed radiofrequency ablation for the

treatment of knee osteoarthritis: A systematic review. Pain Physician. 2017;20(3):155-171.PMID:28339430.

33. Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint

interventions. Pain Physician. 2012;15(3): E247-E278. PMID:22622913.

34. Hetta DF, Mahran AM, Kamal EE. Pulsed radiofrequency treatment for chronic post-surgical orchialgia: A double-blind, sham-

controlled, randomized trial: Three-month results. Pain Physician. 2018;21(2):199-205. PMID: 29565950.

35. Ke M, Yinghui F, Yi J, et al. Efficacy of pulsed radiofrequency in the treatment of thoracic postherpetic neuralgia from the

angulus costae: A randomized, double-blinded, controlled trial. Pain Physician. 2013;16(1):15-25. PMID :23340530.

36. Kesikburun S, Yaşar E, Uran A, et al. Ultrasound-guided genicular nerve pulsed radiofrequency treatment for painful knee

osteoarthritis: A preliminary report. Pain Physician. 2016;19(5 :E751-E759.PMID:27389118.

37. Kestranek J, Spacek J, Ryska P, et al. Radiofrequency therapy for severe idiopathic vulvodynia. J Low Genit Tract Dis.

2013;17(4):e1-e4.PMID:23903198.

38. Kim JH, Kim E, Kim BI. Pulsed radiofrequency treatment of the superior hypogastric plexus in an interstitial cystitis patient with

chronic pain and symptoms refractory to oral and intravesical medications and bladder hydrodistension: A case report.

Medicine (Baltimore). 2016;95(49): e5549.PMID:27930554.

39. Kim YK, Jung I, Lee CH, et al. Pulsed radiofrequency ablation under ultrasound guidance for huge neuroma. Korean J Pain.

2014;27(3):290-293.PMID:25031817.

40. Lee JJ, Sohn JH, Choi HJ, et al. Clinical efficacy of pulsed radiofrequency neuromodulation for intractable meralgia paresthetica.

Pain Physician. 2016;19(3):173-179.PMID:27008291.

41. Lindner R, Sluijter ME, Schleinzer W. Pulsed radiofrequency treatment of the lumbar medial branch for facet pain: A

retrospective analysis. Pain Med. 2006;7(5):435-439.PMID:17014603.

42. Lopez BC, Hamlyn PJ, Zakrzewska JM. Systematic review of ablative neurosurgical techniques for the treatment of trigeminal

neuralgia. Neurosurgery. 2004;54(4):973-982; discussion 982-983.PMID:12823880.

43. Luleci N, Ozdemir U, Dere K et al. Evaluation of patients’ response to pulsed radiofrequency treatment applied to the

suprascapular nerve in patients with chronic shoulder pain. J Back Musculoskelet Rehabil. 2011;24(3):189-94. PMID :21849733.

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E155.PMID:25794213.

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873.PMID:18084976.

46. Malik K, Benzon HT. Radiofrequency applications to dorsal root ganglia: A literature review. Anesthesiology. 2008;109(3):527-

542.PMID:18719452

47. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in

chronic spinal pain. Part II: Guidance and recommendations. Pain Physician. 2013;16(2 Suppl):S49-S283.PMID:23615883.

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2000;4(6):437-444.PMID:11060589.

49. Manolitsis N, Elahi F. Pulsed radiofrequency for occipital neuralgia. Pain Physician 2014; 17(6): E709-E717. PMID:25415786.

50. Martin DC, Willis ML, Mullinax LA, et al. Pulsed radiofrequency application in the treatment of chronic pain. Pain Pract.

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51. Mikeladze G, Espinal R, Finnegan R, et al. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain.

Spine J. 2003;3(5):360-362.PMID:14588947.

52. Misra S, Ward S, Coker C. Pulsed radiofrequency for chronic testicular pain-a preliminary report. Pain Med. 2009;10(4):673-678.

PMID:19302438.

53. Naderi Nabi B, Sedighinejad A, Haghighi M, et al. Comparison of transcutaneous electrical nerve stimulation and pulsed

radiofrequency sympathectomy for treating painful diabetic neuropathy. Anesth Pain Med. 2015;5(5) :e29280.PMID:26587405.

54. Nagar VR, Birthi P, Grider JS, Asopa A. Systematic review of radiofrequency ablation and pulsed radiofrequency for

management of cervicogenic headache. Pain Physician. 2015;18(2):109-130. PMID:25794199.

55. Nagda JV, Davis CW, Bajwa ZH et al. Retrospective review of the efficacy and safety of repeated pulsed and continuous

radiofrequency lesioning of the dorsal root ganglion/segmental nerve for lumbar radicular pain. Pain Physician. 2011;14(4):371-

6.

56. Navani A, Mahajan G, Kreis P, Fishman SM. A case of pulsed radiofrequency lesioning for occipital neuralgia. Pain Med.

2006;7(5):453-456. PMID:17014606.

57. Osman AM, El-Hammady DH, Kotb MM. Pulsed compared to thermal radiofrequency to the medial calcaneal nerve for

management of chronic refractory plantar fasciitis: A prospective comparative study. Pain Physician. 2016;19(8): E1181-

E1187.PMID: 27906949.

58. Park HG, Park PG, Kim WJ, et al. Ultrasound-assisted mental nerve block and pulsed radiofrequency treatment for intractable

postherpetic neuralgia: Three case studies. Korean J Pain. 2014;27(1):81-85. PMID: 24478907.

59. Park SM, Cho YW, Ahn SH, et al. Comparison of the effects of ultrasound-guided interfascial pulsed radiofrequency and

ultrasound-guided interfascial injection on myofascial pain syndrome of the gastrocnemius. Ann Rehabil Med. 2016;40(5):885-

892. PMID: 27847719.

60. Picelli A, Lobba D, Vendramin P, et al. A retrospective case series of ultrasound-guided suprascapular nerve pulsed

radiofrequency treatment for hemiplegic shoulder pain in patients with chronic stroke. J Pain Res. 2018;11: 1115-1120. PMID:

29942146.

61. Rhame EE, Levey KA, Gharibo CG. Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency. Pain

Physician. 2009;12(3):633-638.PMID: 19461829.

62. Schianchi PM, Sluijter ME, Balogh SE. The treatment of joint pain with intra-articular pulsed radiofrequency. Anesth Pain Med.

2013;3(2):250-255.

63. Schianchi PM. A new technique to treat facet joint pain with pulsed radiofrequency. Anesth Pain Med. 2015;5(1): e21061.

64. Shah RV, Racz GB. Long-term relief of posttraumatic headache by sphenopalatine ganglion pulsed radiofrequency lesioning: A

case report. Arch Phys Med Rehabil. 2004;85(6):1013-1016.PMID:15179659.

65. Shanthanna H, Chan P, McChesney J, et. al. Pulsed radiofrequency treatment of the lumbar dorsal root ganglion in patients with

chronic lumbar radicular pain: a randomized, placebo-controlled pilot study. J Pain Res 2014:7 47-55. PMID:24453500.

66. Simopoulos TT, Kraemer J, Nagda JV, et al. Response to pulsed and continuous radiofrequency lesioning of the dorsal root

ganglion and segmental nerves in patients with chronic lumbar radicular pain. Pain Physician. 2008;11(2):137-

144.PMID:18354708.

67. Tamimi MA, McCeney MH, Krutsch J. A case series of pulsed radiofrequency treatment of myofascial trigger points and scar

neuromas. Pain Med. 2009;10(6):1140-1143.PMID:19594852.

68. Taverner MG, Loughnan TE, Soon CW, et al. Transcutaneous application of pulsed radiofrequency treatment for shoulder pain.

Pain Pract. 2013;13(4):310-315.PMID:22863196.

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Page | 10 of 11 ∞

70. Teixeira A, Sluijter ME. Intradiscal high-voltage, long-duration pulsed radiofrequency for discogenic pain: A preliminary report.

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Neurother. 2007;7(5):471-472.PMID:17492898.

73. Terkawi AS, Romdhane K. Ultrasound-guided pulsed radiofrequency ablation of the genital branch of the genitofemoral nerve

for treatment of intractable orchalgia. Saudi J Anaesth. 2014;8(2):294-298.PMID:24843352.

74. Thapa D, Ahuja V. Combination of diagnostic medial calcaneal nerve block followed by pulsed radiofrequency for plantar

fascitis pain: A new modality. Indian J Anaesth. 2014;58(2):183-185.PMID:24963184.

75. Todorov L. Pulsed radiofrequency of the sural nerve for the treatment of chronic ankle pain. Pain Physician. 2011;14(3):301-4.

PMID: 21587334.

76. Vallejo R, Benyamin RM, Kramer J, et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain

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77. Van Boxem K, van Bilsen J, de Meij N, et al. Pulsed radiofrequency treatment adjacent to the lumbar dorsal root ganglion for

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radicular pain: A double blind sham controlled randomized clinical trial. Pain. 2007;127(1-2):173-182.PMID:17055165.

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study with 6 months of follow-up. Reg Anesth Pain Med. 2010;35(2):148-151.PMID:20301822.

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84. Werner MU, Bischoff JM, Rathmell JP, Kehlet H. Pulsed radiofrequency in the treatment of persistent pain after inguinal

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headache. J Headache Pain. 2011 12(5):569-71. PMID:216118080..

History

Page | 11 of 11 ∞

Date Comments 09/01/18 New policy, approved August 14, 2018, effective December 6, 2018. Add to Surgery

section. Policy created with a literature review through July 2018. Pulsed

radiofrequency for the treatment of various chronic pain syndromes is considered

investigational.

10/01/19 Annual Review, approved September 5, 2019. Policy updated with literature review.

References added. Policy statement unchanged.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The

Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and

local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review

and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit

booklet or contact a member service representative to determine coverage for a specific medical service or supply.

CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2019 Premera

All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when

determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to

the limits and conditions of the member benefit plan. Members and their providers should consult the member

benefit booklet or contact a customer service representative to determine whether there are any benefit limitations

applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Discrimination is Against the Law

Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Premera: • Provides free aids and services to people with disabilities to communicate

effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible

electronic formats, other formats) • Provides free language services to people whose primary language is not

English, such as: • Qualified interpreters• Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email AppealsDepartmentInquiries@Premera.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Getting Help in Other Languages

This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-722-1471 (TTY: 800-842-5357).

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)

้ี ี ้ ู ํ ั ้ี ี ้ ู ่ี ํ ั ่ี ั ั ื ัุ ุ ่ ี ํ ี ุ ้ํ ิ ํ ่ี ่ ่ื ั ั ุ ุ ื ่ ื ่ีี ่ ้ ่ ุ ี ิ ิ ่ี ้ ั ้ ู ่ ื ้ี ุ ี ่ ้ ่

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).