Minimally Invasive Procedures for Back Pain (including basivertebral nerve ablation)
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Medical coverage criteria and policy stance for minimally invasive interventional procedures to treat low back pain, including basivertebral nerve ablation and various intradiscal and disc decompression techniques, for Blue Cross Blue Shield - Rhode Island members.
No material clinical or coverage changes in this revision.
Coverage Criteria
BVN ablation (Intracept®) — medical necessity
Thermal destruction of the intraosseous basivertebral nerve (e.g., Intracept® system) is considered medically reasonable and necessary when ALL of the following are met and no contraindications are present:
Thermal destruction of the intraosseous BVN must only be performed once per vertebral body from L3-S1 per lifetime; up to 4 vertebral bodies may be treated during one procedure.
Procedures with insufficient evidence
Evidence-based coverage stance summaries for specified procedures:
Well-designed RCTs are needed.
Numerous case series/uncontrolled studies reported improvements but lack of controlled trials limits interpretation.
High-quality randomized trials with adequate follow-up are needed.
Percutaneous thermal intradiscal procedures (TIPs) — procedures that insert catheters or probes into the disc to apply heat or disruption — are addressed separately in this policy. The policy explicitly lists TIPs (including intradiscal electrothermal annuloplasty and related techniques) as not covered for Medicare Advantage Plans per CMS determinations and, where evidence is insufficient, as not medically necessary for Commercial Products. (See the policy's evidence summaries for intradiscal annuloplasty and related procedures.)
Thermal destruction of the intraosseous basivertebral nerve (eg, Intracept®) is treated as a distinct intervention and is considered medically reasonable and necessary when the specific BVN ablation criteria in this policy are met (including chronic lumbar pain ≥6 months, MRI evidence of Modic type 1 or 2 changes at L3–S1, multidisciplinary evaluation, and absence of contraindications).
The Centers for Medicare & Medicaid Services (CMS) has determined that Percutaneous Thermal Intradiscal Procedures (TIPs) are not reasonable and necessary for treatment of low back pain; accordingly, TIPs are not covered for Medicare Advantage Plans. The policy lists CPT codes 22526 and 22527 specifically as TIPs that are not covered for Medicare Advantage Plans when identified as such.
Providers should not expect Medicare Advantage payment for services billed using those codes when the procedure is performed as a TIP; verify benefit rules and prior authorization requirements before scheduling services for MA members.
This medical policy is provided for informational purposes and does not guarantee payment. Coverage and payment are determined by the member's subscriber agreement, member certificate, or employer agreement, which supersede this policy. For member-specific benefits, providers must contact the provider call center to verify eligibility and coverage prior to providing services.
The policy separates covered and non-covered intradiscal and disc-decompression procedures. Procedures listed as having insufficient evidence or not covered include: intradiscal electrothermal annuloplasty (IDET) / intradiscal radiofrequency annuloplasty / intradiscal biacuplasty, laser discectomy, automated percutaneous discectomy, and disc nucleoplasty (radiofrequency coblation).
Thermal destruction of the intraosseous basivertebral nerve (BVN ablation / Intracept®) is addressed independently and may be considered medically necessary when policy criteria are met; CPT codes for BVN ablation (see coding section) reflect that distinction.
CPT codes 22526 and 22527 (percutaneous intradiscal electrothermal annuloplasty, single and additional levels) are identified in this policy as TIPs and are therefore not covered for Medicare Advantage Plans. The policy also states these codes are considered not medically necessary for Commercial Products when used for TIPs.
The policy groups TIP codes separately from the CPT codes used to report thermal destruction of the intraosseous basivertebral nerve (BVN ablation), reflecting a different coverage stance for those interventions.
The policy explicitly lists CPT codes 22526 and 22527 as not medically necessary for Commercial Products and not covered for Medicare Advantage Plans when identified as Percutaneous Thermal Intradiscal Procedures (TIPs).
Providers should ensure correct coding and clinical documentation; billing TIPs for covered conditions may trigger claim denial under MA plans and may be subject to medical necessity review for Commercial products.
Coding
| No codes listed |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) |
| 22526 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level |
| 22527 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure) |
| 62287 | Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle-based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar (Text Revision Effective 1/1/2026) |
| 62330 | Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (ie, ct or fluoroscopy), bilateral; one interspace, lumbar (New Code Effective 1/1/2026) |
| 62331 | Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (ie, ct or fluoroscopy), bilateral; additional interspace(s), lumbar (list separately in addition to code for primary procedure) (New Code Effective 1/1/2026) |
| S2348 | Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, using radiofrequency energy, single or multiple levels, lumbar |
Provider Actions & Requirements
Obtain prior authorization for BVN ablation
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products for thermal destruction of the intraosseous basivertebral nerve (e.g., Intracept® system).
Follow related payer prior‑authorization policy
When prior authorization rules are governed by the payer's general prior authorization policy, providers should follow that related policy and obtain authorization when required (see 'Prior Authorization of Services, Treatments or Procedures').
- Related policy reference: Prior Authorization of Services, Treatments or Procedures
Verify prior authorization per member benefits
Prior authorization and payment are ultimately determined by the member's subscriber or employer agreement and provider participation agreements; contact the provider call center for member‑specific prior authorization requirements.
- Member benefit documents supersede this policy
- Contact provider call center for benefits/eligibility
Confirm ≥6 months of conservative therapy
Patients must have failed ≥6 months of non‑surgical management before BVN ablation is considered; examples of non‑surgical management include activity modification, physical therapy, injections, and pharmacotherapy.
- Minimum duration: ≥6 months of conservative care
- Examples: chiropractic manipulation, physical therapy, injection therapy (epidural and/or facet), specific lumbar exercise, pharmacotherapy
Document multidisciplinary screening prior to procedure
Providers must ensure multidisciplinary screening and evaluation (including psychological and physical evaluation) has been completed and documented prior to BVN ablation; documentation must be available in the patient chart if requested.
- Multidisciplinary screening required (psychological and physical)
- Chart documentation must be available upon request
Confirm no contraindications before BVN ablation
Thermal destruction of the intraosseous BVN should be performed only when no contraindications listed in the policy are present (e.g., skeletally immature, active infection, BMI >40, prior surgery at the intended level except specified exceptions).
- Review contraindications before scheduling: age ≤18, active infection, bleeding diathesis, pregnancy, prior lumbar surgery at intended level (exceptions apply), BMI >40, etc.
Required documentation for BVN ablation
Documentation must include baseline pain and disability assessment, history of ≥6 months of conservative (non‑surgical) management, multidisciplinary screening, MRI evidence of Modic type 1 or 2 changes at L3–S1, and chart evidence available upon request.
- Baseline pain and disability scale at baseline
- History of ≥6 months non‑surgical management
- MRI showing Modic type 1 or 2 changes at L3–S1
- Multidisciplinary screening documentation (including psychological and physical)
Verify benefits and obtain member‑specific authorization
For member‑specific benefits, coverage determinations, and prior authorization, contact the provider call center; benefits and eligibility are determined by the member's subscriber or employer agreement which supersede this policy.
- Contact provider call center for benefits/eligibility
- Member documents supersede policy
Do not bill for non‑covered TIPs and related procedures
The following procedures are not covered or are considered not medically necessary: percutaneous annuloplasty (IDET, IDTA, biacuplasty), laser discectomy, radiofrequency coblation (disc nucleoplasty), and automated percutaneous discectomy; TIPs (22526, 22527) are not covered when identified as TIPs.
Risk of denial for non‑medically necessary or non‑covered services
Services determined to be not medically necessary or non‑covered benefits may be denied and the provider may not charge the member unless the member was informed and agreed in writing in advance.
- Do not bill member for denied services unless prior written agreement exists
- Denied services are not payable
Background
Chronic low back pain (cLBP) can originate from vertebral endplate degeneration and associated inflammation that is perceived by the basivertebral nerve, producing a clinical syndrome termed vertebrogenic pain characterized by midline, deep, aching or burning low back pain often without radicular findings.
Thermal destruction of the intraosseous basivertebral nerve (BVN ablation, e.g., Intracept®) is a minimally invasive, image-guided procedure supported by randomized, sham-controlled trials in appropriately selected patients with MRI evidence of Modic type 1 or 2 changes at vertebral levels from L3–S1. When the policy's selection criteria are met (including ≥6 months of failed non-surgical management and multidisciplinary evaluation), BVN ablation may be considered medically reasonable and necessary.
Definitions
Conservative Treatment Requirements
Required prior to consideration of BVN ablation (≥6 months conservative management)
Prior to consideration of thermal destruction of the intraosseous basivertebral nerve, the following conservative management requirement must be met:
Non-surgical management may include activity modification, chiropractic manipulation, physical therapy, cognitive support, injection therapy (epidural and/or facet), spine biomechanics education, specific lumbar exercise, home heat/cold, low-impact aerobic exercise, and pharmacotherapy (eg, NSAIDs, muscle relaxants, neuroleptics, narcotics).
Conservative treatment requirements (empty/placeholder)
Examples of conservative treatments (for documentation and clinical context):
This block is a placeholder matching the policy's list of non-surgical management options.
Frequency Limits
Imaging Requirements
Obtain MRI (Modic changes) and use fluoroscopy during BVN ablation
MRI demonstrating Type 1 or Type 2 Modic changes at one or more vertebrae from L3–S1 is required for patient selection, and the procedure is performed under fluoroscopic imaging.
- MRI evidence of Modic type 1 or 2 changes at L3–S1 required
- Fluoroscopic imaging required during the procedure
Note imaging/navigation assistance referenced in literature and guidelines
References cited in the policy include imaging‑ and navigation‑assisted procedures (for example CT‑navigation for PELD) and guideline documents, underscoring that imaging and navigation techniques are referenced in the literature for related spine procedures.
- Examples in references: CT navigation for PELD, NICE guidance on percutaneous procedures
Not Covered
The policy lists procedures and techniques that are not covered or considered to have insufficient evidence to support medical necessity. These include intradiscal annuloplasty procedures (electrothermal or radiofrequency, including CPT 22526 and 22527 when identified as TIPs), laser discectomy, radiofrequency coblation (disc nucleoplasty), and automated percutaneous discectomy.
Additionally, several newer percutaneous decompression codes (for example, CPT codes 62287, 62330, 62331, and HCPCS S2348) are identified in the policy as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products.
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