ModifiedBlue Cross Blue Shield - LouisianaPolicy 00077

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation

Clinical coverage and investigational guidance for intradiscal thermal procedures and intraosseous basivertebral nerve (BVN) ablation for chronic low back pain for members of Blue Cross and Blue Shield of Louisiana.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyBVN ablation; intradiscal annuloplasty, radiofrequency annuloplasty, biacuplasty coverage guidance

Policy CodePolicy 00077

Change TypeCoverage criteria added and eligibility/criteria revised (material)

Effective Date06/14/2026

Next Review DateMar 1, 2027

Key ActionObtain prior authorization with documentation of ≥6 months supervised conservative management and MRI showing Modic Type 1 or 2 at L3–S1.

SourceLink

POLICY UPDATE CHANGES

Added coverage with criteria for thermal destruction of the lumbar intraosseous basivertebral nerve (BVN) for select chronic low back pain.

Removed criteria bullet requiring Oswestry Disability Index (ODI) ≥ 30 and revised conservative management and MRI Modic-type imaging criteria for BVN ablation.

Added criterion that basivertebral nerve ablation may not be combined with any other procedure on the same day.

6 moConservative care minimum

L3–S1Eligible levels

VAS ≥4

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Modic 1/2Required MRI findings

InvestigationalStance on intradiscal annuloplasty

CPT 5 codesAssociated codes

Coverage Criteria

Thermal destruction of lumbar intraosseous basivertebral nerve (BVN) — medical necessity

Covered when ALL of the following are met:

Patient status and symptoms: Skeletally mature patient with chronic lumbar back pain for at least 6 months and a baseline Visual Analogue Scale (VAS) score >= 4 on most days.VAS >= 4; >=6 months

Conservative management: Documented failure to respond to at least 6 consecutive months of supervised non-surgical conservative management including physical therapy (or supervised home exercise program) AND at least one complementary conservative treatment (eg, anti-inflammatory medications/analgesics, nerve membrane stabilizers or muscle relaxants, passive/active modalities, acupuncture, chiropractic manipulation, massage, activity modification).>= 6 months

Evaluation to exclude other causes: Other possible pain sources (including but not limited to fracture, tumor, infection, or significant spinal deformity) have been ruled out and imaging findings correlate with clinical presentation.

Imaging findings: MRI demonstrates Modic Type 1 or Type 2 changes in at least one vertebral endplate at one or more levels from L3 through S1; only levels with Modic Type 1 or 2 changes will be approved for ablation. Modic subcriteria include fibrovascular bone marrow changes (hypointense T1 signal; Modic 1) or fatty bone marrow changes (hyperintense T1 and T2 signal; Modic 2).Modic Type 1 or 2; L3-S1

Absence of investigational/exclusion situations: Absence of any situations listed as investigational or exclusionary per policy (see investigational/exclusion criteria).

BVN ablation - Covered with criteria

Coverage for intraosseous basivertebral nerve (BVN) ablation is provided when ALL of the following are met:

Duration of pain: Chronic low back pain of at least 6 months duration.>=6 months

Conservative management: Documented failure to respond to at least 6 months of nonsurgical management (supervised non-surgical conservative management as defined in policy).>=6 months

Imaging requirement: MRI demonstrating Modic Type 1 or Type 2 changes in at least one vertebral endplate at one or more levels from L3 through S1; includes fibrovascular (Modic 1) and fatty marrow (Modic 2) subcriteria.Modic type 1 or 2; L3-S1

Percutaneous intradiscal annuloplasty, radiofrequency annuloplasty, and biacuplasty — investigational / not covered

Not covered / Investigational

Intradiscal annuloplasty and related procedures: Percutaneous annuloplasty procedures (including intradiscal electrothermal annuloplasty/IDET, intradiscal radiofrequency annuloplasty/percutaneous intradiscal radiofrequency thermocoagulation, and intradiscal biacuplasty) for chronic discogenic back pain are considered investigational and not medically necessary based on the available evidence.

Intradiscal thermal procedures - Investigational / noncovered

Procedures considered investigational or not supported by sufficient evidence:

Thermal intradiscal procedures (TIPS): Intradiscal electrothermal annuloplasty (IDET), percutaneous intradiscal radiofrequency thermocoagulation/annuloplasty, and intradiscal biacuplasty are considered investigational or noncovered depending on external guidance; Medicare (CMS) has determined thermal intradiscal procedures to be noncovered.

The policy lists specific exclusions and investigational situations for intraosseous basivertebral nerve (BVN) ablation. BVN ablation is considered investigational and will be denied when any of the following apply: the patient is skeletally immature (generally <18 years); has severe cardiac or pulmonary compromise; is undergoing concurrent vertebral augmentation at the intended levels; has Modic changes at levels outside L3–S1; has radicular pain correlating with nerve compression; has prior lumbar spine surgery at the intended treatment level (except prior discectomy/laminectomy >6 months earlier with resolved radicular pain); or has symptomatic spinal stenosis confirmed by imaging.

Thermal intradiscal procedures (TIPS), including IDET and percutaneous intradiscal radiofrequency thermocoagulation, are designated as noncovered under the Centers for Medicare & Medicaid Services national coverage determination. The policy notes CMS has determined these procedures are "not reasonable and necessary" for treatment of low back pain and therefore noncovered.

The policy takes an investigational stance on intradiscal electrothermal annuloplasty (IDET), intradiscal radiofrequency annuloplasty, and biacuplasty because available randomized trials and systematic reviews provide limited, inconsistent, or insufficient evidence of net clinical benefit. Small RCTs and reviews reported conflicting or nonconfirmatory results and methodological limitations, leading the Company to classify these intradiscal thermal annuloplasty techniques as investigational and not medically necessary for chronic discogenic back pain.

Available evidence for percutaneous intradiscal radiofrequency thermocoagulation and IDET is limited and inconsistent. Systematic reviews and guideline assessments have described the evidence as limited-to-fair or inconsistent, and NICE recommends use only with special arrangements; existing RCTs have reported mixed results and are insufficient to establish a clear net health benefit.

Conservative Treatment Requirements

Documented failure to respond to at least 6 consecutive months of supervised non-surgical conservative management is required prior to BVN ablation consideration.

Required components of conservative care: Conservative management must include physical therapy (or supervised home exercise program with initial instruction and documented compliance) AND at least one complementary conservative treatment such as anti-inflammatory medications/analgesics, nerve membrane stabilizers or muscle relaxants, passive/active modalities, acupuncture, chiropractic manipulation, massage, activity modification, or supervised rest.>= 6 months

Documentation of failure: Patient must have completed a full course of the conservative management program for the current episode and demonstrate no significant improvement or worsening on clinical reevaluation prior to consideration of BVN ablation.>= 6 months

Imaging Requirements

Prior Authorization

Prior Authorization and Documentation

Prior authorization is required. Documentation must include: clinical history, duration of symptoms, VAS score, detailed conservative therapy records showing at least 6 consecutive months of supervised non‑surgical management (physical therapy or supervised home exercise program plus at least one complementary treatment such as anti‑inflammatories/analgesics, nerve membrane stabilizers or muscle relaxants, passive/active modalities, activity/lifestyle modification), records showing worsening or no significant improvement on clinical reevaluation, and imaging reports (MRI) read by an independent radiologist. If there is a discrepancy in imaging interpretation, the radiology report supersedes. Only levels with MRI‑demonstrated Modic Type 1 or 2 changes (L3–S1) will be approved for ablation. The results of imaging studies must correlate with the clinical findings in support of the requested procedure.

Prior authorization required
Imaging read by independent radiologist; radiology report supersedes if discrepancy
Include documentation of 6 months conservative care and clinical reevaluation showing inadequate response
Only vertebral levels with Modic Type 1 or 2 changes (L3–S1) may be approved

Provider Actions & Documentation

Prior Authorization

Prior authorization: document failure of conservative management

Prior authorization requests must include documentation that the member completed and failed a full course of conservative management, and imaging read by an independent radiologist showing Modic Type 1 or 2 changes at L3–S1 when applicable.

Prior Authorization

Administrative prior authorization may be required for listed CPT codes

Services associated with this policy (e.g., CPT 22526, 22527, 22899, 64628, 64629) may require prior authorization consistent with the payer's administrative rules.

Step Therapy

Conservative therapy prerequisite: document prior PT + complementary treatment ≥6 months

Document prior conservative therapies including physical therapy plus at least one complementary conservative treatment strategy, with a combined duration of at least 6 months.

Physical therapy (or supervised home program with initial instruction and compliance documented)

Coding

Codes used to identify services associated with this policyCPT

22526
22527
22899
64628
64629

HCPCSHCPCS

No codes listed

ICD-10 DiagnosisICD-10

All related diagnoses

ICD-10 Diagnosis — all related diagnoses

Minimum duration of conservative care

Minimum duration of conservative care>= 6 months (documented failure of at least 6 consecutive months of supervised non-surgical conservative management)

Required conservative modalitiesPhysical therapy or supervised home exercise program PLUS at least one complementary treatment (e.g., NSAIDs/analgesics, nerve membrane stabilizers, muscle relaxants, passive/active modalities, acupuncture, chiropractic, massage)

Pain severity thresholdVAS >= 4 on most days

Frequency Limits

BVN ablation — frequency limits

Frequency limitRepeat basivertebral nerve (BVN) ablation at the same vertebral level is not allowed (lifetime)

Same-day proceduresBVN ablation may not be combined with any other spine procedure on the same day

Contraindication implicationPrior repeat at same level is listed among investigational/noncovered situations

Basivertebral nerve ablation — frequency guidance

Repeat procedure policyRepeat BVN ablation at the same vertebral level is not permitted

Investigational exclusionsA repeat procedure at the same level is listed as a situation rendering BVN ablation investigational/not covered

Definitions

Discogenic low back pain (definition)

DefinitionDiscogenic low back pain: low back pain without radicular symptoms associated with radiologically confirmed degenerative disc disease

Typical featuresMultifactorial syndrome; pain localized to the lumbar spine without nerve root signs

Imaging correlationAssociated with degenerative changes on radiologic studies

Vertebrogenic pain / Basivertebral nerve (BVN) ablation

DefinitionVertebrogenic pain: pain arising from vertebral endplate pathology transmitted via the basivertebral nerve (BVN); BVN ablation is thermal intraosseous ablation targeting these nerves to treat chronic low back pain associated with Modic changes

Anatomic levelsProcedure targets BVN branches entering posterior vertebral body at levels L3 through S1

Background

Discogenic low back pain is a multifactorial syndrome of axial low back pain without radicular symptoms that is associated with radiologically confirmed degenerative disc disease. Intradiscal electrothermal therapies aim to thermocoagulate annular nociceptors and modify annular tissue, whereas basivertebral nerve (BVN) ablation targets vertebrogenic pain transmitted via the intraosseous BVN and is directed at vertebral endplate pathology associated with Modic type 1 or 2 changes on MRI.

Not Covered

The policy explicitly lists the following procedures as NOT COVERED: percutaneous intradiscal electrothermal annuloplasty/IDET, intradiscal radiofrequency annuloplasty (percutaneous intradiscal radiofrequency thermocoagulation), and intradiscal biacuplasty. In addition, the policy reiterates that thermal intradiscal procedures (TIPS) are noncovered per the CMS national coverage determination.

Revision History

2026-03-11revisionLatest

Removed Oswestry Disability Index (ODI) ≥ 30 requirement; revised conservative management examples to require documented failure of at least 6 consecutive months of supervised non-surgical conservative management; revised MRI Modic Type 1/2 imaging criteria to add sub-bullets for fibrovascular and fatty marrow changes; added criterion prohibiting BVN ablation to be combined with any other procedure on the same day.

2024-06-12addition

Added coverage with criteria for thermal destruction of the lumbar intraosseous basivertebral nerve (BVN) for select chronic low back pain and added investigational situations for intraosseous radiofrequency ablation when coverage criteria are not met.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyBVN ablation; intradiscal annuloplasty, radiofrequency annuloplasty, biacuplasty coverage guidance

Policy CodePolicy 00077

Change TypeCoverage criteria added and eligibility/criteria revised (material)

Effective Date06/14/2026

Next Review DateMar 1, 2027

Key ActionObtain prior authorization with documentation of ≥6 months supervised conservative management and MRI showing Modic Type 1 or 2 at L3–S1.

SourceLink

On This Page

Anatomic limitation: Affected levels must be within L3 through S1; only levels with Modic Type I or II changes approved for ablation.L3-S1

Procedural restriction: Basivertebral nerve ablation may not be combined with any other procedure on the same day.

Must have failed at least 6 months of nonsurgical care prior to BVN ablation consideration (supporting node)

Must have failed at least 6 months of nonsurgical care prior to BVN ablation consideration.

Duration requirement: Failure to respond to at least 6 months of nonsurgical management is required before BVN ablation will be considered.>= 6 months

Reference guidance: This duration and failure requirement aligns with ISASS guidance and policy history revisions requiring documented nonsurgical management prior to coverage.

Denial Risk

CMS Noncoverage for Thermal Intradiscal Procedures

The Centers for Medicare & Medicaid Services (CMS) noncoverage determination for thermal intradiscal procedures (eg, intradiscal electrothermal therapies) remains in effect; these intradiscal thermal procedures are not covered and are distinct from intraosseous basivertebral nerve (BVN) ablation. Ensure submitted requests specify intraosseous BVN ablation and include required MRI findings (Modic Type 1 or 2) and conservative therapy documentation to avoid denial.

CMS noncoverage applies to intradiscal thermal procedures (not intraosseous BVN ablation)
Do not bill/report intradiscal thermal procedures for this indication

Documentation Required

Conservative Therapy Requirement for BVN Ablation

All of the following conservative therapy requirements must be documented prior to consideration for BVN ablation: completion of a full course of conservative management for the current episode (minimum 6 consecutive months), participation in supervised physical therapy or a supervised home exercise program, use of at least one complementary treatment (eg, anti‑inflammatory medications/analgesics, nerve membrane stabilizers, muscle relaxants, passive/active modalities, activity/lifestyle modification), and documentation of worsening or no significant improvement on clinical reevaluation. Documentation of compliance with the plan of therapy is required. BVN ablation should be considered only when more invasive therapies are being contemplated.

Minimum 6 consecutive months of documented conservative care
Supervised PT or supervised home exercise program plus ≥1 complementary treatment
Clinical reevaluation showing worsening or no significant improvement
Documentation that more invasive therapies are being considered

At least one complementary treatment (e.g., anti-inflammatories/analgesics, nerve membrane stabilizers, passive/active modalities, acupuncture, chiropractic, massage, activity modification)

Step Therapy

BVN ablation prerequisite: ≥6 months documented nonsurgical management failure

For BVN ablation specifically, submit documentation that the patient failed to respond to at least 6 consecutive months of nonsurgical (supervised) management prior to consideration of ablation.

Documentation Required

Required supporting documentation for medical necessity

Submit records supporting medical necessity including documentation of supervised conservative management (details of physical therapy or supervised home program, complementary treatments), clinical reevaluation notes showing lack of improvement, and independent radiology reports correlating imaging with clinical findings.

Records of physical therapy or supervised home exercise with compliance or clinician attestation
Documentation of complementary conservative treatments used
Clinical reevaluation notes showing no significant improvement or worsening
Independent radiology report demonstrating Modic Type 1 or 2 and correlation with clinical findings

Documentation Required

Documentation must support coding and medical necessity standards

Documentation submitted must support the CPT codes reported and demonstrate medical necessity per the policy definitions; determinations are based on nationally accepted standards and peer‑reviewed evidence.

Denial Risk

Denial risk: investigational procedures and contraindications

Procedures deemed investigational (e.g., percutaneous intradiscal annuloplasty, intradiscal radiofrequency annuloplasty, biacuplasty) and BVN ablation when eligibility criteria or listed contraindications are present will be denied as investigational.

Ensure patient is not skeletally immature, has no excluded comorbidities (e.g., severe cardiac/pulmonary compromise, active infection, MRI contraindication), and meets other listed eligibility criteria before submission

Denial Risk

CMS: TIPS are noncovered (Medicare NCD)

Medicare’s National Coverage Determination states that thermal intradiscal procedures (TIPS), including IDET and percutaneous intradiscal radiofrequency thermocoagulation, are noncovered.

Policy history noteRestriction on repeat procedure at same level was added in policy history

Regulatory noteFDA-cleared Intracept system indicated for L3–S1 BVN ablation for chronic LBP >=6 months not responsive to >=6 months conservative care

TIPS (Thermal intradiscal procedures)

ShorthandTIPS = Thermal Intradiscal Procedures

Included proceduresExamples include intradiscal electrothermal annuloplasty (IDET), percutaneous intradiscal radiofrequency thermocoagulation/annuloplasty, and biacuplasty

Evidence/coverage stanceThese thermal intradiscal procedures have limited/inconsistent evidence and are considered investigational or noncovered per guidance (e.g., CMS NCD)

Modic Type 1 / Type 2 (MC1/MC2) — imaging explanation

Modic types requiredModic Type 1 or Type 2 endplate changes (MC1 or MC2) on MRI are required imaging findings for BVN ablation eligibility

Modic 1 characteristicsFibrovascular bone marrow changes with hypointense T1 signal, representing inflammation/edema/disruption

Modic 2 characteristicsFatty bone marrow changes with hyperintense T1 and T2 signal, representing fatty replacement of marrow

2025-06-05administrative_review

Medical Policy Committee review and addition of a Policy Guidelines section; coverage criteria bullet added for absence of investigational situations.