CurrentBluecross IdahoPolicy MP 7.01.572

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

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Defines coverage and medical necessity criteria for percutaneous intradiscal electrothermal annuloplasty, radiofrequency annuloplasty, intradiscal biacuplasty, and intraosseous basivertebral nerve (BVN) ablation for chronic low back pain under Bluecross Idaho benefit plans.

Policy Summary

PayerBluecross Idaho

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

Policy CodePolicy MP 7.01.572

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 30, 2026

Key ActionObtain prior authorization documenting ≥6 months of failed conservative management, MRI evidence of Modic-type endplate changes at L3–S1, and baseline ODI and VAS values when requesting BVN ablation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsminimum duration of chronic low back pain required for BVN ablation

VAS ≥ 4minimum pain severity (VAS) for BVN ablation

ODI ≥ 30minimum Oswestry Disability Index for BVN ablation

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CurrentBluecross IdahoPolicy MP 7.01.572

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

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Policy Summary

PayerBluecross Idaho

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

Policy CodePolicy MP 7.01.572

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 30, 2026

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsminimum duration of chronic low back pain required for BVN ablation

VAS ≥ 4minimum pain severity (VAS) for BVN ablation

ODI ≥ 30minimum Oswestry Disability Index for BVN ablation

Modic Type I/IIrequired MRI endplate change evidence for BVN ablation

3+minimum conservative modalities attempted

NCD 150.11CMS determination on thermal intradiscal procedures

Coverage and Medical Necessity Criteria

Intraosseous BVN ablation — Initial therapy

Thermal intraosseous basivertebral nerve (BVN) ablation is considered medically necessary when ALL of the following are met:

BVN medical necessity: Individual is skeletally mature (generally ≥18 years); chronic lumbar back pain for at least 6 months with a minimum Visual Analog Scale (VAS) score ≥ 4 on most days; Oswestry Disability Index (ODI) ≥ 30 indicating functional impairment; documented failure of at least 6 consecutive months of non-surgical management including at least 3 of the specified conservative modalities; pain sources such as fracture, tumor, or infection have been ruled out; MRI demonstrates Modic Type I (or Type I and II) changes in endplates of one or more vertebrae from L3–S1 and absence of non-vertebrogenic pathology that could explain the pain; and a statement from an appropriate licensed provider attesting to the absence of untreated major mental health contributors.see nodes

All listed items required; exclusion criteria detailed separately.

Percutaneous intradiscal annuloplasty/biacuplasty

Policy stance on percutaneous intradiscal annuloplasty and biacuplasty:

Intradiscal annuloplasty/biacuplasty: Percutaneous annuloplasty procedures (intradiscal electrothermal annuloplasty, intradiscal radiofrequency annuloplasty, and intradiscal biacuplasty) for treatment of chronic discogenic back pain are considered investigational and not medically necessary based on available evidence.

Two RCTs of electrothermal annuloplasty reported conflicting results; biacuplasty trials are limited and lack definitive sham-controlled evidence.

Evidence and study selection

Evidence review and principles used to select studies informing efficacy and durability:

Study selection principles: Preference given to randomized controlled trials for efficacy; when RCTs are unavailable, comparative prospective observational studies preferred; single-arm studies considered for long-term outcomes or safety; duplicative or overlapping populations excluded.

See study selection criteria.

Intradiscal electrothermal annuloplasty RCT evidence: Two randomized controlled trials exist with conflicting results (Pauza et al. 2004 reported benefit; Freeman et al. 2005 found no benefit and was stopped early), and no recent high-quality RCTs since 2005.

Conflicting/older RCTs limit conclusions.

Outcomes and follow-up: Relevant outcomes include symptoms, functional status, quality of life, and treatment-related morbidity; follow-up of at least 6–12 months is recommended to assess durability of effect.6-12 months follow-up

Used to inform coverage decisions.

Basivertebral nerve ablation (device indication)

FDA-cleared device indication considerations for basivertebral nerve ablation systems:

Basivertebral nerve ablation (Intracept) indication: Devices (eg, Intracept systems) are intended for ablation of basivertebral nerves of L3–S1 for relief of chronic low back pain of at least 6 months' duration that has not responded to at least 6 months of conservative care; device labeling describes accompanying features consistent with Modic Type 1 or Type 2 MRI findings.symptoms ≥6 months; failed ≥6 months conservative care

FDA 510(k) summaries and cleared indications referenced.

Evidence summaries and follow-up requirements

Evidence summaries and recommended follow-up used to interpret clinical benefit:

Percutaneous intradiscal radiofrequency thermocoagulation evidence: Two sham-controlled randomized trials showed no benefit of percutaneous intradiscal radiofrequency thermocoagulation versus sham; one trial reported only 1 of 14 treatment successes and another was terminated for futility.RCT evidence negative

Barendse et al. (2001) and Kvarstein et al. (2009).

Intradiscal electrothermal annuloplasty evidence: Two RCTs reported conflicting results (one positive, one negative) with the most recent RCT from 2005; evidence is therefore inconsistent.conflicting/older RCTs

Follow-up of at least 6–12 months is recommended.

Clinical endpoints and follow-up: Key outcomes include symptoms, function, quality of life, and treatment-related morbidity; follow-up of at least 6–12 months is recommended to evaluate durability.

BVN ablation (trial-based criteria)

Coverage may be considered when ALL of the following trial-based criteria (as used in SMART and INTRACEPT) are met:

BVN trial-based eligibility: 1) Chronic isolated lumbar pain ≥6 months unresponsive to ≥6 months of nonoperative management; 2) Baseline ODI ≥30 and VAS ≥4; 3) MRI-demonstrated Modic Type 1 or 2 changes at targeted vertebral endplates; 4) Treatment limited to specified lumbar levels (L3–S1) with the number of levels consistent with trial protocols (eg, SMART: 2–3 consecutive levels; INTRACEPT: up to 4 non-consecutive levels); 5) Documentation of prior conservative therapies (eg, physical therapy, medications, injections) and required prior-auth documentation.see thresholds module

Derived from SMART and INTRACEPT trial inclusion criteria.

Intradiscal biacuplasty (study considerations)

Study-based eligibility concepts and limitations for intradiscal biacuplasty:

Biacuplasty trial-based eligibility: Trials enrolled highly selected patients (eg, many screened patients failed to meet strict inclusion criteria); some trials required positive provocation discography; subjects had prior conservative management; limitations include industry sponsorship, lack of sham controls in some trials, and high screen-failure rates.refer to individual trial protocols

Derived from Kapural et al. and Desai et al. trials.

Intraosseous basivertebral nerve ablation — coverage criteria

Covered when ALL of the following are met:

Patient selection: Chronic axial low back pain of at least 6 months' duration.>=6 months

(trial and guideline criteria)

Conservative therapy: Failure to respond to at least 6 months of nonsurgical/conservative management.>=6 months

(supported by trial inclusion and guideline statements)

Imaging: MRI demonstrating Modic Type 1 (inflammatory/edema) or Type 2 (fatty) changes in at least one vertebral endplate at L3–S1.Modic 1 or 2 at >=1 level L3-S1

(per international society guideline)

ISASS candidate criteria

ISASS and ASPN guideline–based candidate considerations for intraosseous basivertebral nerve ablation:

ISASS criteria for considering intraosseous basivertebral nerve ablation: Chronic low back pain of at least 6 months' duration AND failure of at least 6 months of nonsurgical management AND MRI-demonstrated Modic Type 1 or Type 2 endplate changes at one or more levels from L3 to S1.

ISASS guideline describes Modic features (inflammation/edema for MC1; fatty marrow change for MC2).

The policy lists specific exclusion and contraindication criteria. Key exclusions include: skeletally immature individuals (generally <18 years), active spine or systemic infection, spinal malignancy, severe cardiopulmonary compromise, conditions causing fragility of bone such as osteoporosis (T-score ≤ -2.5) or metabolic bone disease, recent trauma or compression fracture at the target level, concurrent vertebral augmentation at the same levels, and prior lumbar spine surgery at the same levels (with a narrow exception for discectomy/laminectomy >6 months earlier with resolved radicular pain).

Additional exclusion factors that may preclude coverage are clinical or radiographic findings not compatible with the studied indications: radicular pain or symptomatic spinal stenosis, Modic changes located outside L3–S1, disc extrusion/protrusion >5 mm at L3–S1, spondylolisthesis >2 mm, spondylolysis, degenerative scoliosis, or facet arthropathy/effusion correlated with facet-mediated low back pain.

Behavioral and other patient-level contraindications include Beck Depression Inventory score >24, ≥3 Waddell signs, active untreated substance abuse, compensated injury or ongoing litigation, current use of extended‑release narcotics, BMI >40, contraindications to MRI, pregnancy or lactation, and allergies or active implantable devices incompatible with the procedure.

This evidence review does not address disc nucleoplasty (Coblation®) or laser discectomy; those techniques are evaluated separately under evidence review MP 7.01.93 and are outside the scope of this policy.

Two sham‑controlled randomized trials of percutaneous intradiscal radiofrequency thermocoagulation found no benefit compared with sham. Barendse et al. (2001) randomized 28 patients and observed no superiority of active treatment at 8 weeks, and a later trial (Kvarstein et al., 2009) was discontinued for futility after interim analysis showed no trend to benefit; at 12 months there were no significant differences between groups.

Randomized trials of intradiscal biacuplasty have been industry‑sponsored and enrolled highly selected populations. One trial reported a significant difference for the primary outcome at 6 months but not at earlier time points, and the other trial had a high screen‑failure rate (only ~6% of screened subjects enrolled). Limitations include lack of sham control, potential for placebo effects, crossover, and unclear power in some studies, restricting generalizability beyond the rigorously selected trial populations.

Several BVN studies and systematic reviews explicitly excluded patients with clinical evidence of symptomatic spinal stenosis or radicular pain. Therefore, presentations dominated by radiculopathy or neurogenic claudication were not the populations studied and are not indications supported by the reviewed intradiscal/BVN trials.

CMS has determined that thermal intradiscal procedures, including IDET and percutaneous intradiscal radiofrequency thermocoagulation, are not reasonable and necessary for low back pain and therefore are noncovered under the Medicare National Coverage Determination (NCD).

Percutaneous annuloplasty procedures (intradiscal electrothermal annuloplasty, intradiscal radiofrequency annuloplasty, intradiscal biacuplasty) are considered investigational by this policy due to inconsistent or insufficient evidence from randomized trials and lack of definitive long‑term comparative benefit.

The evidence base includes two RCTs for electrothermal annuloplasty with conflicting results and no recent supportive trials; sham‑controlled trials of intradiscal radiofrequency thermocoagulation showed no benefit; biacuplasty trials are limited to selected populations and lack adequate sham‑controlled evidence. Given these limitations, the policy does not support routine coverage for these percutaneous intradiscal procedures.

Intradiscal electrothermal annuloplasty (IDET) evidence comprises two randomized trials with conflicting outcomes and no recent RCTs since 2005. Because results are inconsistent and the overall quality and recency of data are limited, IDET lacks robust evidence of consistent clinical benefit.

Percutaneous intradiscal radiofrequency thermocoagulation has been evaluated in sham‑controlled randomized trials that failed to demonstrate superiority to placebo; consequently, the procedure lacks evidence of efficacy and is not supported as an effective treatment for discogenic low back pain.

Several intradiscal procedures lack supportive comparative evidence in broad populations. The available RCTs are either industry‑sponsored, underpowered, non‑sham‑controlled, or enroll highly selected patients with high screen‑failure rates. These limitations—combined with inconsistent trial results and limited long‑term comparative data—mean that electrothermal annuloplasty, radiofrequency annuloplasty, and biacuplasty do not have sufficient evidence to establish net health benefit for routine coverage.

Overall, the evidence is insufficient to support routine use of intradiscal annuloplasty or biacuplasty. Conflicting RCT results for electrothermal annuloplasty, negative sham‑controlled trials for radiofrequency thermocoagulation, and limited, selected biacuplasty trials mean that clinical effectiveness has not been established across broader patient populations.

Based on the evidence review, thermal intradiscal procedures (including intradiscal electrothermal annuloplasty and percutaneous intradiscal radiofrequency thermocoagulation) do not have sufficient evidence of net clinical benefit and are treated as noncovered per the cited evidence assessments and the Medicare NCD. Intradiscal biacuplasty similarly lacks conclusive sham‑controlled data to support routine coverage.

Coding and Regulatory References

Regulatory / Device Codesmixed

GEI	FDA product code referenced for radiofrequency disc catheter devices

Procedure/CPT codesCPT

22526	Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level.
22527	Percutaneous intradiscal electrothermal annuloplasty, including fluoroscopic guidance; single level or 1 or more additional levels (List separately in addition to code for primary procedure).
22899	Unlisted procedure code, spine.
62290	Injection procedure for discography, each level; lumbar.
62291	Injection procedure for discography, each level; cervical or thoracic.
64628	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (used for Intracept® system).
72285	Discography, cervical or thoracic, radiological supervision and interpretation.
72295	Discography, lumbar, radiological supervision and interpretation.

ICD-10-PCS codesICD-10

0R530ZZ, 0R550ZZ, 0R590ZZ, 0R5B0ZZ, 0S520ZZ, 0S540ZZ

ICD-10-PCS destruction codes for upper and lower joint disc procedures; ICD-10-PCS codes are used for inpatient services.

Diagnosis codesICD-10

ICD-10-CM: All Diagnoses

Policy applies to all diagnoses per ICD-10-CM statement in the document.

Beck Depression Inventory (BDI) — threshold

Beck Depression Inventory (BDI) threshold> 24

Use in exclusion screeningBDI > 24 is listed as an exclusion/denial trigger

Documentation implicationProvider statement should attest absence of untreated major mental health contributors; BDI >24 may preclude coverage

Visual Analog Scale (VAS) — threshold

Visual Analog Scale (VAS) minimumVAS ≥ 4 on most days

ContextRequired as part of BVN ablation inclusion criteria (chronic lumbar back pain with minimum VAS ≥4)

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Medical necessity — document all required clinical, imaging, and therapy criteria

Thermal intraosseous basivertebral nerve (BVN) ablation is considered medically necessary only when all required clinical, imaging, conservative-therapy, and exclusion criteria are documented. Required elements include: skeletal maturity; ≥6 months of chronic lumbar back pain with VAS ≥4 on most days; ODI ≥30; documented failure of ≥6 consecutive months of non-surgical management with at least 3 modalities; exclusion of alternate pain sources (fracture, tumor, infection, significant spinal deformity); MRI evidence of Modic Type I (or Type I and II) changes at one or more vertebral endplates from L3–S1; and an attestation from an appropriate licensed provider that untreated major mental health contributors are absent.

Skeletally mature patient.
Chronic lumbar back pain ≥6 months; VAS ≥4 on most days.
Oswestry Disability Index (ODI) ≥30.
Failure of ≥6 consecutive months non‑surgical management with ≥3 modalities.
MRI: Modic Type I or Type I/II changes at ≥1 level L3–S1 and absence of non‑vertebrogenic pathology.
Provider statement attesting absence of untreated major mental health contributors.

Clinical Background and Scope

The policy explicitly lists intradiscal electrothermal annuloplasty, intradiscal radiofrequency annuloplasty, and intradiscal biacuplasty as not covered / investigational. Percutaneous intradiscal radiofrequency thermocoagulation is described in sham‑controlled trials with no benefit and is therefore unsupported; CMS NCD guidance further deems thermal intradiscal procedures noncovered for Medicare beneficiaries.

Key Definitions

Discogenic low back pain definition

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

Clinical featuresMultifactorial syndrome involving axial low back pain linked to degenerative disc changes on imaging

DistinctionDoes not primarily include radicular findings; focus is on disc/endplate-related pain

Basivertebral nerve (BVN) ablation / vertebrogenic pain

DefinitionBasivertebral nerve (BVN) ablation: thermal destruction of intraosseous nerves entering the posterior vertebral body to reduce vertebrogenic axial low back pain

Target anatomyBasivertebral nerve enters posterior vertebral body and sends branches to superior and inferior endplates

Conservative Care Prerequisites

≥ 3 modalities tried

Conservative treatment prerequisite before consideration of BVN ablation:

Minimum conservative duration and modalities: Documented failure to respond to at least 6 consecutive months of non-surgical management, evidenced by trial of at least 3 or more modalities such as activity modification, a course of physical therapy/therapeutic exercise, chiropractic manipulation, cognitive therapy, pharmacotherapy (narcotic or non-narcotic), and injection therapy for implicated pain sources.>= 6 months; ≥ 3 modalities tried

Documentation should list modalities and durations.

Prior conservative care documentation recommended before basivertebral nerve ablation

Prior conservative care documentation is recommended before basivertebral nerve ablation:

Prior conservative care documentation: Prior authorization and medical records should document chronic low back pain duration, specific conservative therapies attempted, and that the patient failed to respond to at least 6 months of conservative care as required by device labeling and trial inclusion criteria.

Treatment Frequency and Level Limits

BVN ablation — SMART trial level limits (min 2, max 3 consecutive vertebral levels L3–S1)

SMART trial level limitsMinimum 2 and maximum 3 consecutive vertebral levels (L3 to S1)

Trial basisSMART trial inclusion limited treatment to 2–3 consecutive levels within L3–S1

Coverage implicationWhen using SMART-based criteria, planned treatment should adhere to 2–3 consecutive levels L3–S1

BVN ablation — INTRACEPT trial allowed up to 4 non-consecutive vertebrae

INTRACEPT trial allowanceTreatment allowed up to 4 non-consecutive vertebrae from L3 to S1

ContrastINTRACEPT permitted non-consecutive levels (up to 4) vs SMART's consecutive-level restriction

Imaging and Diagnostic Requirements

Documentation Required

Imaging requirement: MRI with Modic changes documented

For intraosseous BVN ablation, include MRI demonstrating Modic changes (Type I or Type II) in the record; MRI evidence of Modic Type I or Type I/II changes at one or more vertebrae L3–S1 is required per the coverage criteria.

Attach MRI report with Modic Type I or Type I/II description
Confirm Modic changes are at L3–S1 levels

Documentation Required

Imaging: MRI describing Modic changes for BVN ablation

MRI must document Modic type 1 or 2 changes when used to support basivertebral nerve ablation candidacy; device summaries and trial criteria describe Modic 1 or 2 features as part of the indication.

Documentation Required

Procedures Not Covered

Discogenic low back pain is characterized as chronic low back pain without radicular findings associated with degenerative disc disease. Treatments discussed include intradiscal thermal procedures that attempt to modify annular tissue or nociceptors, and intraosseous basivertebral nerve (BVN) ablation that targets intraosseous nerve branches transmitting vertebrogenic pain from endplate degeneration.

Policy Summary

PayerBluecross Idaho

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

Policy CodePolicy MP 7.01.572

Change TypeNo material change

Effective DateApr 30, 2026

Last ReviewApr 30, 2026

Next Review DateApr 30, 2026

SourceLink

On This Page

6-12 months follow-up

Recommended for outcome assessment.

Trial thresholdsSMART and other trials used VAS ≥4 as baseline eligibility

Oswestry Disability Index (ODI) — threshold

Oswestry Disability Index (ODI) minimumODI ≥ 30 (100‑point scale)

ContextRequired as part of BVN ablation inclusion criteria indicating functional impairment

Used in trialsSMART and INTRACEPT trials required ODI ≥30 at baseline

recommended follow-up duration

Recommended follow-up durationAt least 6 to 12 months (study follow-up recommended to assess durability)

RationaleOutcomes of interest include symptoms, function, QOL and treatment morbidity with 6–12 month follow-up recommended

Trial reportingSMART and INTRACEPT reported outcomes up to 12–24 months but recommended minimum follow-up is 6–12 months

Minimum Oswestry Disability Index (ODI)

Minimum Oswestry Disability Index (ODI) for trial eligibilityODI ≥ 30 (on 100‑point scale)

Trial referenceSMART trial inclusion required ODI ≥30 at baseline

Implication for prior authorizationDocument baseline ODI ≥30 when seeking BVN ablation coverage per trial-based criteria

Minimum visual analog scale (VAS)

Minimum Visual Analog Scale (VAS) for trial eligibilityVAS ≥ 4

Trial referenceSMART trial required VAS ≥4 as baseline eligibility

Documentation noteRecord baseline VAS score (≥4) for BVN ablation prior authorization

Vertebral levels treated (SMART trial constraints)

SMART trial vertebral-level limitsMinimum 2 and maximum 3 consecutive vertebral levels from L3 to S1

Level rangeTargets limited to L3–S1 in SMART trial inclusion criteria

ImplicationPlanned treated levels should be within L3–S1 and respect consecutive-level limits for SMART-based eligibility

INTRACEPT allowed treatment (trial constraints)

INTRACEPT trial allowanceUp to 4 non-consecutive vertebrae from L3 to S1 were allowed

Contrast with SMARTINTRACEPT permitted treatment of up to 4 non-consecutive levels vs SMART's 2–3 consecutive levels

Documentation implicationIf following INTRACEPT-based criteria, document planned non-consecutive levels (≤4) within L3–S1

Conservative care duration (key value)

Conservative modalitiesFailure of ≥6 months including at least 3 modalities (eg, activity modification, physical therapy, injections, pharmacotherapy)

Device labeling and guideline supportFDA Intracept indication and ISASS guidance cite ≥6 months prior conservative care

Duration of nonoperative management

Duration of nonoperative management required>= 6 months of nonsurgical management prior to BVN ablation

Trial and guideline basisSMART and INTRACEPT trials and ISASS criteria required ≥6 months of nonoperative care

Prior authorization implicationDocument duration and failure of nonoperative therapies (≥6 months) when requesting BVN ablation

Prior Authorization

Prior authorization — include conservative care history and MRI findings

When requesting prior authorization, include documentation of chronic low back pain duration, details of failed conservative care (typically ≥6 months when cited by device labeling and trials), and relevant MRI findings such as Modic changes at target levels.

Duration of symptoms (≥6 months).
Specific conservative therapies tried and their durations (see conservative-therapy requirement).
MRI report describing Modic type 1 or 2 changes at L3–S1 as applicable.

Prior Authorization

Prior authorization — demonstrate discogenic/vertebrogenic diagnosis and prior care

Prior authorization should document that the indication aligns with discogenic/vertebrogenic pain populations: diagnosis of discogenic back pain or vertebrogenic pain, detailed prior conservative management including duration, and planned follow-up of clinical outcomes for at least 6–12 months.

Clinical diagnosis consistent with discogenic or vertebrogenic back pain.
List of prior conservative treatments and durations (supporting failure/inadequate response).
Follow-up plan with outcomes assessment over 6–12 months.

Prior Authorization

Prior authorization — confirm BVN trial‑based eligibility (ODI, VAS, Modic)

For BVN ablation prior authorization, confirm trial-based eligibility where applicable: chronic isolated lumbar pain unresponsive to ≥6 months nonoperative management; baseline ODI ≥30 and VAS ≥4; and MRI evidence of Modic type 1 or 2 changes at targeted levels (L3–S1).

Document ODI and VAS baseline scores (ODI ≥30; VAS ≥4).
Document Modic type 1 or 2 at intended treatment levels (L3–S1).
State number and levels planned consistent with trial limits (e.g., SMART: 2–3 consecutive levels; INTRACEPT: up to 4 non‑consecutive levels).

Billing Rule

Prior authorization — include referenced CPT and ICD‑10‑PCS codes

Include the policy codes when requesting review; the listed CPT and inpatient ICD‑10‑PCS codes should be provided with the prior authorization submission for reference.

CPT examples: 22526, 22527, 22899, 62290, 62291, 64628, 72285, 72295.
ICD‑10‑PCS inpatient destruction codes listed in the policy (e.g., 0R530ZZ, 0R550ZZ, 0R590ZZ, 0R5B0ZZ, 0S520ZZ, 0S540ZZ).

Billing Rule

Prior authorization — coding references and use of CPT 64628

When submitting a prior authorization, reference the policy CPT/ICD codes and include supporting clinical documentation—CPT 64628 is the code used for thermal destruction of the intraosseous basivertebral nerve (includes imaging guidance).

Use CPT 64628 for thermal destruction of intraosseous basivertebral nerve (first 2 vertebral bodies).
Include discography/diagnostic procedure codes (62290/62291, 72285/72295) if performed and relevant to the request.

Step Therapy

Conservative therapy requirement — ≥6 months and ≥3 modalities documented

Documented failure of at least 6 consecutive months of non‑surgical management is required; the record must show attempts at three or more conservative modalities (e.g., activity modification, physical therapy, chiropractic manipulation, cognitive therapy, pharmacotherapy, injections).

Minimum 6 months of nonoperative management.
At least 3 distinct conservative modalities must be documented.

Step Therapy

Stepwise management implied — attempt and document conservative care first

Providers should follow stepwise management: conservative therapies should be attempted and documented prior to consideration of procedures such as BVN ablation, consistent with device labeling and trial inclusion criteria.

Document progression through conservative options and rationale for escalation to procedural intervention.
Cite device labeling and trial-based requirement of failure of ≥6 months conservative care when applicable.

Documentation Required

Conservative therapy as comparator — document prior nonoperative care

Conservative management (pain medications, physical therapy, exercise, chiropractic care, acupuncture, spinal injections) served as the comparator in trials and should be documented as the preceding therapy before intradiscal or BVN procedures.

List specific conservative treatments used and response.
If surgical decompression was considered, document why it was not indicated or was declined.

Documentation Required

Conservative therapy prerequisite — document failure of ≥6 months nonoperative care

Prior to BVN ablation, document failure or inadequate response to at least 6 months of conservative, nonsurgical management including exact therapies tried and duration, consistent with trial and guideline prerequisites.

Specify dates and durations for each conservative modality.
Describe objective or patient‑reported lack of adequate improvement.

Step Therapy

Conservative therapy prerequisite — supported by trials and guidelines (≥6 months)

Clinical trials and device labeling support the requirement that conservative therapy be attempted for ≥6 months before BVN ablation; include this information in the authorization and clinical record.

Reference trial inclusion criteria and ISASS guidance when applicable.
Ensure conservative-therapy documentation aligns with the ≥6‑month requirement.

Documentation Required

Conservative therapy supported by trials/guidelines — include baseline ODI, VAS, and MRI

Clinical trials and the policy recommend documenting baseline outcome measures (e.g., Oswestry Disability Index and visual analog scale) and imaging (MRI with Modic changes) as suggested evidence elements when seeking authorization or documenting care.

Record baseline ODI and VAS scores (ODI ≥30; VAS ≥4 when meeting trial criteria).
Attach MRI showing Modic type 1 or 2 changes at targeted levels L3–S1.

Documentation Required

Required documentation for BVN ablation — failure of 6 months + imaging and exclusions

Prior authorization and documentation must show failure of at least 6 consecutive months of non‑surgical management with at least three conservative modalities, plus imaging confirming Modic Type I (or Type I/II) changes at L3–S1 and exclusion of non‑vertebrogenic pathology.

Explicit documentation of the three or more conservative modalities and their durations.
MRI report confirming Modic Type I or Type I/II endplate changes at one or more levels from L3–S1.
Clinical notes ruling out fracture, tumor, infection, or other non‑vertebrogenic causes.

Documentation Required

Documentation should include symptom duration, conservative care, and imaging

Provider documentation should include symptom duration, prior conservative management with durations (at least 6 months when applicable), and imaging findings (Modic changes described for BVN ablation).

Duration of chronic low back pain.
Detailed list of prior conservative therapies and their timeframes.
MRI findings describing Modic type and level(s).

Documentation Required

Required clinical documentation and planned follow‑up (6–12 months)

Required clinical documentation and follow-up should state the diagnosis of discogenic or vertebrogenic back pain, prior conservative care and its duration, MRI evidence of Modic changes when applicable, and a plan for outcomes follow-up for at least 6–12 months.

Diagnosis consistent with discogenic/vertebrogenic pain.
Conservative-treatment history and failure documentation.
Follow-up plan to assess symptoms, function, and QOL over 6–12 months.

Documentation Required

Suggested documentation elements — baseline ODI, VAS, and MRI

Suggested documentation elements include baseline outcome measures used in trials (Oswestry Disability Index and visual analog scale) and MRI evidence of Modic changes; include these in the record to support medical necessity.

Baseline ODI and VAS scores.
Imaging demonstrating Modic type 1 or 2 changes at targeted levels.
Trial‑consistent documentation of conservative therapy failure.

Documentation Required

Suggested required documentation — chronicity, conservative care, MRI, and planned levels

Suggested required documentation for authorization: duration of chronic low back pain (≥6 months), prior conservative care attempts with durations (≥6 months), MRI demonstrating Modic type 1 or 2 changes at L3–S1, and the planned level(s) for BVN ablation.

Document chronic pain ≥6 months.
List prior conservative therapies and durations (≥6 months total).
Include MRI images/reports showing Modic changes and specify target vertebral levels (L3–S1).

Documentation Required

Required clinical documentation for BVN ablation — chronicity, failed nonsurgical care, MRI Modic

For intraosseous basivertebral nerve ablation, required clinical documentation should demonstrate chronic low back pain ≥6 months, failure of ≥6 months of nonsurgical management, and MRI evidence of Modic type 1 or 2 changes at one or more levels L3–S1 as applicable.

Chronic low back pain ≥6 months documented in clinical notes.
Clear record of attempted nonsurgical management for ≥6 months and lack of adequate response.
MRI evidence of Modic type 1 or 2 changes at one or more L3–S1 levels.

Denial Risk

Exclusion criteria — presence of listed exclusions may trigger denial

Presence of any exclusion criteria listed in the policy should be documented and will trigger denial if present (examples include: skeletally immature, spine infection or cancer, osteoporosis T‑score ≤ -2.5, prior lumbar surgery at the same levels, radicular pain, symptomatic spinal stenosis, Modic changes outside L3–S1, BMI >40, active substance abuse, BDI >24, ≥3 Waddell signs, compensated injury/litigation, contraindications to MRI, pregnancy).

Confirm absence of exclusion criteria in the chart; if present, procedure may be denied.
Examples of exclusions are explicitly listed in the policy and must be checked.

Denial Risk

Denial risk — insufficient evidence or missing prior conservative‑care documentation

Procedures lacking adequate evidence or performed without documented prior conservative care—including cases where device labeling or trials require ≥6 months conservative care—may be denied for lack of supporting evidence or failure to meet prerequisites.

If the device indication or trials require ≥6 months conservative care, lack of that documentation risks denial.
Procedures without sufficient evidence in broader populations are at risk for noncoverage.

Denial Risk

Denial risk — lack of demonstrated benefit in sham‑controlled trials

Procedures supported only by trials that showed no benefit compared with sham (for example, percutaneous intradiscal radiofrequency thermocoagulation) are at risk for denial due to lack of demonstrated efficacy.

Barendse et al. and Kvarstein et al. trials showed no advantage over sham for intradiscal radiofrequency thermocoagulation.
Such evidence may lead to noncoverage decisions for those procedures.

Denial Risk

Evidence limitations — trial weaknesses may affect coverage

Evidence limitations—such as small trials, high crossover rates, lack of sham controls, short follow‑up, or limited generalizability—may affect coverage decisions; document how the patient aligns with studied populations to mitigate denial risk.

High crossover in RCTs (e.g., SMART and INTRACEPT) limits long‑term comparative data.
Where trials are small or unblinded, document why the patient matches the trial population to support medical necessity.

Denial Risk

Evidence‑limit denial risk — high crossover or absent sham controls affect long‑term comparability

Therapies lacking comparative long‑term data due to high crossover or absence of sham controls may lead to coverage denial if medical necessity is not clearly established with supporting documentation linking the patient to trial‑eligible characteristics.

Explain and document why the patient is similar to study populations (Modic changes, duration, ODI/VAS thresholds) to support the request.
Acknowledge limitations of available comparative long‑term data in the record.

Denial Risk

Medicare NCD — thermal intradiscal procedures are noncovered by CMS

Medicare has determined that thermal intradiscal procedures (including IDET and percutaneous intradiscal radiofrequency thermocoagulation) are not reasonable and necessary; such procedures are noncovered under CMS guidance and claims for these procedures risk denial for Medicare beneficiaries.

CMS NCD states thermal intradiscal procedures are noncovered for treatment of low back pain.
For Medicare patients, reference the NCD when billing or seeking authorization for these thermal intradiscal procedures.

Indication contextUsed to treat vertebrogenic pain associated with endplate degeneration and Modic changes

Intradiscal biacuplasty definition

DefinitionIntradiscal biacuplasty: a procedure using two cooled radiofrequency electrodes placed posterolaterally in the annulus to ablate annular nociceptive fibers

MechanismCooling probes allow treatment of a larger annular area than standard needle probes

Trial contextBiacuplasty has been evaluated in randomized trials with strict inclusion criteria and high screen-failure rates

Basivertebral nerve ablation (Intracept)

DefinitionBasivertebral nerve ablation (Intracept): an intraosseous radiofrequency ablation procedure targeting basivertebral nerves entering posterior vertebral body to relieve vertebrogenic chronic low back pain

FDA-cleared indicationIntended for ablation of basivertebral nerves of L3–S1 for chronic low back pain ≥6 months unresponsive to ≥6 months conservative care; Modic Type 1 or 2 features described

Coding noteCPT 64628 describes thermal destruction of intraosseous basivertebral nerve including imaging guidance for first 2 vertebral bodies

Percutaneous intradiscal radiofrequency annuloplasty / thermocoagulation

DefinitionPercutaneous intradiscal radiofrequency annuloplasty/thermocoagulation: percutaneous placement of RF probe into disc to thermally modify annular tissue

Procedure detailsDirect application of RF energy; example device (Radionics RF Disc Catheter) activates at ~70°C for 90 seconds

Policy stanceRandomized sham-controlled trials show no benefit for percutaneous intradiscal RF thermocoagulation; considered noncovered in some contexts

Intradiscal radiofrequency biacuplasty

DefinitionIntradiscal radiofrequency biacuplasty: bipolar RF therapy using two transdiscal probes intended to ablate annular nociceptive fibers

TechniqueTwo cooled/bipolar probes placed transdiscally to treat annular tissue

Evidence noteTrials (e.g., Kapural 2013, Desai 2016) show some short-term benefits but have limitations including high screen-failure rates and lack of long-term comparative data

Intradiscal radiofrequency biacuplasty

DefinitionIntradiscal radiofrequency biacuplasty (term): transdiscal radiofrequency annuloplasty using two transdiscal probes to treat discogenic low back pain

Synonym/contextOften referred to simply as biacuplasty in trials and literature

Clinical considerationEvidence limited to selected trial populations; not established for broad routine coverage

Vertebrogenic back pain

DefinitionVertebrogenic back pain: low back pain thought to originate from vertebral endplate pathology targeted by basivertebral nerve ablation

PathophysiologyRelated to endplate damage/degeneration and intraosseous nerve transmission via BVN

Imaging correlateAssociated with Modic type 1 or 2 changes on MRI at affected levels

Biacuplasty (term)

Term definitionBiacuplasty: transdiscal radiofrequency annuloplasty using two probes to deliver bipolar RF energy to the annulus

Intended effectAblate annular nociceptive fibers to reduce discogenic pain

Evidence cautionTrials have high screen-failure rates and limited long-term comparative data

Basivertebral nerve (BVN) ablation (term)

Term definitionBasivertebral nerve (BVN) ablation: percutaneous intraosseous radiofrequency or thermal ablation targeting the BVN to reduce vertebrogenic axial low back pain

Associated imagingSelection often requires MRI evidence of Modic type 1 or 2 changes at L3–S1

Device exampleIntracept system is an example of an FDA-cleared BVN ablation device

Modic changes definition

DefinitionModic changes: MRI signal changes in vertebral endplates indicative of vertebrogenic pathology; includes Type 1 (inflammatory/edema) and Type 2 (fatty) changes

Clinical relevancePresence of Modic Type 1 or 2 changes at L3–S1 is a selection criterion for BVN ablation trials and guidelines

Imaging descriptionType 1: inflammation/edema (hypointense on T1); Type 2: fatty marrow replacement (hyperintense on T1)

Include details of therapies, dates, and response; imaging findings should accompany documentation.

Conservative management is a relevant comparator and should be documented prior to considering intradiscal procedures.

Conservative management is a relevant comparator and should be documented prior to considering intradiscal procedures:

Conservative comparator documentation: Conservative management and/or surgical decompression are relevant comparators; documentation should show prior conservative care attempts and their duration before intradiscal procedures are considered.

Used to contextualize efficacy comparisons and prior authorization reviews.

Documentation of failure or inadequate response to ≥6 months of conservative management prior to considering BVN ablation.

Documentation requirement prior to considering BVN ablation:

Failure/inadequate response to conservative management: Documentation should demonstrate failure or inadequate response to at least 6 months of conservative, nonsurgical management (including modalities listed in policy) before BVN ablation is considered.>=6 months

Clinical trial protocols and guidance support this duration.

Documented failure of conservative care

Required documentation demonstrating failure of conservative care:

Documented failure of conservative care: Medical record must show attempts at nonsurgical management for at least 6 months and lack of sufficient clinical improvement, including specific modalities tried and their durations.>=6 months

Provider statement and objective measures (eg, ODI, VAS) recommended.

Documented failure of conservative therapy

Documented failure of conservative therapy required before considering intraosseous BVN ablation:

Documented failure of conservative therapy: Patients should have failed at least 6 months of nonsurgical management prior to consideration of intraosseous basivertebral nerve ablation, consistent with ISASS guidance and trial inclusion criteria.>= 6 months

Include dates and descriptions of therapies tried.

ImplicationDocumentation should specify number and pattern of treated levels when following INTRACEPT protocol

Intraosseous BVN ablation frequency limits (generic entry)

Frequency/recurrence guidanceNo specific repeated-treatment interval stated; trials treated targeted levels once per procedure with level-number limits per protocol

ImplicationRepeat intraosseous BVN ablation at the same level is listed among exclusions/contraindications in policy (repeat procedure at same level discouraged)

DocumentationPrior authorization should include level(s) treated and prior procedures, as repeat same-level treatment may be denied

Codes list fluoroscopic guidance for percutaneous intradiscal procedures and BVN ablation (imaging guidance included in CPT 64628)

Relevant imaging-guidance codingCPT 64628: thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies

Fluoroscopic guidance for intradiscal proceduresCPT codes for intradiscal procedures (eg, 22526, 22527) include fluoroscopic guidance in descriptions

Coding implicationImaging guidance for BVN ablation is included in CPT 64628; additional fluoroscopic guidance codes may be used per procedure descriptions

Follow‑up imaging/assessments: 6–12 months recommended

Studies recommend follow‑up assessments (symptoms and function) and, where applicable, follow‑up imaging over at least 6–12 months to assess outcomes after intradiscal procedures or BVN ablation.

Plan follow‑up assessments with outcomes collection for ≥6–12 months

Documentation Required

Imaging requirement: MRI showing Modic type 1 or 2 changes

MRI demonstrating Modic type 1 or 2 vertebral endplate changes at targeted levels was an inclusion criterion in BVN trials and is part of the policy's selection criteria for BVN ablation.

Documentation Required

Imaging: Modic type 1 or 2 required for BVN candidacy

The policy and device labeling reference MRI evidence of Modic type 1 or type 2 changes as accompanying features supporting basivertebral nerve ablation candidacy.

Documentation Required

Imaging: MRI requirement for intraosseous BVN ablation (L3–S1)

MRI demonstration of Modic type 1 or 2 endplate changes at one or more levels between L3 and S1 is required by ISASS guidance and the policy for consideration of intraosseous basivertebral nerve ablation.