CurrentCareSourcePolicy PASSE-MM-1509

Intraosseous Basivertebral Nerve Ablation

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CareSource coverage and prior authorization for intraosseous basivertebral nerve ablation for vertebrogenic chronic low back pain in Arkansas Medicaid members, including medical necessity criteria, documentation, contraindications, and noncovered services.

Policy Summary

PayerCareSource

PolicyIntraosseous Basivertebral Nerve Ablation

Policy CodePolicy PASSE-MM-1509

Change TypeRevised

Effective DateNov 1, 2026

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit documentation showing all medical necessity criteria are met before requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

The policy updated the definitions of home exercise program and Modic changes.

The policy clarified the pain criteria and contraindications for intraosseous basivertebral nerve ablation.

≥6 monthsRequired low back pain duration

≥6 weeksConservative therapy

L3-S1Qualifying vertebral levels

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CurrentCareSourcePolicy PASSE-MM-1509

Intraosseous Basivertebral Nerve Ablation

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Policy Summary

PayerCareSource

PolicyIntraosseous Basivertebral Nerve Ablation

Policy CodePolicy PASSE-MM-1509

Change TypeRevised

Effective DateNov 1, 2026

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit documentation showing all medical necessity criteria are met before requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

The policy updated the definitions of home exercise program and Modic changes.

The policy clarified the pain criteria and contraindications for intraosseous basivertebral nerve ablation.

≥6 monthsRequired low back pain duration

≥6 weeksConservative therapy

L3-S1Qualifying vertebral levels

Contraindication categories

Not medically necessaryRepeat or additional BVNA

Intraosseous BVNA Coverage Criteria

Initial Intraosseous BVNA Coverage

CareSource considers intraosseous basivertebral nerve ablation (BVNA) medically necessary when ALL of the following clinical criteria are met:

ALL of the following

Member has a diagnosis and documentation of low back pain of at least 6 months duration.
Pain is localized primarily to the lumbar spine without predominant radicular symptoms.
Failure of conservative therapy, as evidenced by documentation in the medical record of at least 6 weeks of active and inactive conservative therapy within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance.
MRI demonstrates Type 1 or Type 2 Modic changes at one or more vertebral endplates from level L3 to S1, corresponding to the member's pain.
Clinical evaluation demonstrates that the member's pain is not primarily attributable to other pain generators, such as symptomatic facet arthropathy, symptomatic lumbar spinal stenosis, or sacroiliac joint dysfunction.
Device is FDA-approved (e.g., Intracept System).
Member does not have any of the following contraindications
- Severe cardiac or pulmonary compromise.
- Active systemic infection or localized infection in the area to be treated.
- Current pregnancy.
- Skeletal immaturity.
- Implantable electronic devices that cannot be safely managed or deactivated during the procedure (e.g., pacemaker, defibrillator).
- Spinal abnormality or anatomic considerations that may preclude safe access to the ablation site (e.g., malignancy, sensitive structure not intended to be ablated).

Repeat or additional intraosseous BVNA is not considered medically necessary.

Monitored anesthesia and conscious sedation during intraosseous BVNA are considered not medically necessary and will not be reimbursed.

Intraosseous BVNA is not medically necessary for indications outside the criteria stated above.

Repeat or additional intraosseous BVNA is not considered medically necessary because it has not been adequately studied in the peer-reviewed medical literature.

Monitored anesthesia and conscious sedation during intraosseous BVNA are not covered because they are considered not medically necessary and will not be reimbursed.

Coverage is limited to the criteria stated above. Intraosseous BVNA is considered not medically necessary for all other indications.

Documentation and Authorization Requirements

Documentation Required

All Medical-Necessity Criteria Required

Document that all CareSource medical-necessity criteria are met before requesting authorization for intraosseous basivertebral nerve ablation (BVNA).

The record must support every required clinical, imaging, treatment-history, device, and safety criterion; failure of any one criterion may result in noncoverage.

Step Therapy

Conservative Therapy Before Ablation

Document failure of conservative therapy before BVNA. The medical record must show at least 6 weeks of both active and inactive conservative therapy within the past 6 months, unless active therapy could not be completed because of a contraindication, increased pain, or intolerance.

Active therapy may include physical therapy, occupational therapy, a physician-supervised home exercise program, and/or chiropractic care.
Inactive therapy may include rest, ice, heat, medical devices, TENS, and/or pharmacotherapy such as prescription or over-the-counter NSAIDs or acetaminophen.

Clinical Background

Vertebrogenic chronic low back pain may arise from degeneration of the vertebral endplates. These degenerative changes can be identified on MRI as Modic changes, which are vertebral bone marrow signal-intensity changes commonly associated with degenerative disc disease. Intraosseous basivertebral nerve ablation is a minimally invasive, image-guided radiofrequency procedure intended to interrupt nociceptive signaling from the vertebral endplates.

Policy Definitions

Chronic low back pain

DefinitionPersistent pain in the lumbar region.

Duration thresholdMore than 12 weeks.

Clinical termChronic low back pain.

Conservative therapy

DefinitionA multimodality plan of care.

Required componentsIncludes both active and inactive conservative therapies.

PurposeProvides the conservative treatment plan before proceeding with ablation.

Required Conservative Treatment

Conservative Treatment Requirements

Coverage requires documented failure of conservative therapy or an accepted reason active therapy could not be completed.

ONE of the following

Failure of active and inactive conservative therapy: The medical record documents failure of at least 6 weeks of both active and inactive conservative therapy within the past 6 months. Active therapies may include physical therapy, occupational therapy, a physician-supervised home exercise program, and/or chiropractic care. Inactive therapies may include rest, ice, heat, medical devices, TENS, and/or pharmacotherapy.At least 6 weeks within the past 6 months
Document the therapies attempted and the member's response.
Inability to complete active conservative therapy
- The member was unable to complete active conservative therapy because of a contraindication.

Frequency and Repeat Procedure Limits

Intraosseous basivertebral nerve ablation

Frequency limitationRepeat or additional intraosseous basivertebral nerve ablation is not considered medically necessary.

RationaleRepeat or additional BVNA has not been adequately studied in the peer-reviewed medical literature.

Coverage statusRepeat or additional BVNA is not medically necessary.

MRI Requirements

Note

MRI requirements for BVNA

For intraosseous basivertebral nerve ablation, obtain MRI documentation demonstrating Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1. The findings must correspond to the member’s pain.

Required imaging: MRI.
Qualifying findings: Type 1 or Type 2 Modic changes.
Qualifying levels: L3 through S1.
Document correspondence between the imaging findings and the member’s pain.

Noncovered Services and Indications

The following are not covered: repeat or additional intraosseous basivertebral nerve ablation; monitored anesthesia during intraosseous BVNA; conscious sedation during intraosseous BVNA; and BVNA for indications outside the stated medical necessity criteria.

Policy Summary

PayerCareSource

PolicyIntraosseous Basivertebral Nerve Ablation

Policy CodePolicy PASSE-MM-1509

Change TypeRevised

Effective DateNov 1, 2026

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionSubmit documentation showing all medical necessity criteria are met before requesting prior authorization.

SourceLink

On This Page

A home exercise program should include specific goals, frequency, expected duration, and a reassessment timeframe; ongoing continuation requires documented clinical progress.

Patient inconvenience or unexplained noncompliance does not establish inability to complete active therapy.

Documentation Required

Clinical Pain Assessment

Include a clinical pain assessment supporting the qualifying pain pattern for BVNA: low back pain documented for at least 6 months, localized primarily to the lumbar spine, and without predominant radicular symptoms.

Document pain duration and lumbar localization.
Document whether radicular symptoms are absent or not predominant.
Document that the pain is not primarily attributable to another pain generator.

Documentation Required

Conservative Treatment History

Provide a treatment history showing the conservative therapies attempted, the duration and timing of treatment, and the member's response. The record must identify both active and inactive modalities or document an accepted reason active therapy could not be completed.

Record the specific therapies attempted, including physical therapy, occupational therapy, supervised HEP, chiropractic care, rest, ice, heat, devices, TENS, and medications when applicable.
Describe response, persistent symptoms, increased pain, intolerance, or contraindication for each relevant therapy.
Confirm that the required treatment occurred within the past 6 months.

Documentation Required

Qualifying MRI Required

Submit MRI documentation demonstrating qualifying Modic changes that correspond to the member's pain.

MRI must show Type 1 or Type 2 Modic changes.
Changes must be present at one or more vertebral endplates from L3 through S1.
Identify the specific vertebral level or levels and document correspondence to the member's pain.
Type 3 Modic changes do not satisfy this criterion.

Unsupported block type: prior_auth

Unsupported block type: denial_risk

Billing Rule

Noncovered Service or Indication

Do not request or bill coverage for services and indications excluded by the policy. Repeat or additional intraosseous BVNA is not medically necessary, and monitored anesthesia or conscious sedation during BVNA will not be reimbursed.

Repeat or additional BVNA is noncovered because it has not been adequately studied in the peer-reviewed medical literature.
Monitored anesthesia and conscious sedation during intraosseous BVNA are not medically necessary and will not be reimbursed.
BVNA for indications outside the stated criteria is not medically necessary.

Active conservative therapies

DefinitionActions or activities that strengthen muscle groups and target key spinal structures.

Included therapiesPhysical therapy, occupational therapy, and physician-supervised home exercise programs.

Additional therapyChiropractic care may also qualify.

Home exercise program

Plan requirementsA prescribed plan with specific goals, frequency, and expected duration.

ReassessmentIncludes a clearly defined timeframe for reassessment, such as 6 to 12 weeks.

ContinuationOngoing continuation must be supported by documented clinical progress.

Insufficient reasonPatient inconvenience or noncompliance without explanation does not constitute an inability to complete the program.

Inactive conservative therapies

DefinitionPassive activities by the patient that aid in treating symptoms associated with pain.

Passive treatmentsRest, ice, heat, medical devices, and Transcutaneous Electrical Nerve Stimulator (TENS) use.

PharmacotherapyPrescription or over-the-counter pharmacotherapy, including non-steroidal anti-inflammatory drugs and acetaminophen.

Modic changes

DefinitionVertebral bone marrow signal intensity changes observable on MRI.

AssociationCommonly associated with degenerative disc disease.

Imaging modalityMRI is used to observe Modic changes.

Modic Change Type 1

T1-weighted imagesHypointense signal.

T2-weighted imagesHyperintense signal.

ClassificationModic Change Type 1.

Modic Change Type 2

T1-weighted imagesHyperintense signal.

T2-weighted imagesHyperintense signal.

ClassificationModic Change Type 2.

Modic Change Type 3

T1-weighted imagesHypointense signal.

T2-weighted imagesHypointense signal.

ClassificationModic Change Type 3.

The member was unable to complete active conservative therapy because it increased pain.

The member was unable to complete active conservative therapy because of intolerance.