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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyHap CareSource MI BVNA Coverage | OpenPayer
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    CurrentHap CareSource MI Coordinated HealthPolicy MM-1832

    Intraosseous Basivertebral Nerve Ablation

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    This policy governs medical necessity and coverage for intraosseous basivertebral nerve ablation for Michigan Coordinated Health members with chronic vertebrogenic low back pain, including eligibility criteria, conservative-treatment requirements, imaging findings, contraindications, and exclusions.

    Policy Summary
    PayerHap CareSource MI Coordinated Health
    PolicyIntraosseous Basivertebral Nerve Ablation
    Policy CodePolicy MM-1832
    Change TypeClinical content update
    Effective DateNovember 1, 2026
    Last ReviewAug 12, 2026
    Next Review DateN/A
    Key ActionSubmit MRI documentation demonstrating Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1 that correspond to the member's pain.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was revised to update the home exercise program and Modic change definitions, clarify pain criteria, and update contraindications and background information.

    ≥6 monthsRequired duration of low back pain
    ≥6 weeksConservative therapy
    L3-S1Eligible vertebral levels
    Type 1 or 2Required MRI pattern

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5Contraindication categories

    BVNA Medical Necessity and Coverage Limits

    Initial BVNA Medical Necessity

    BVNA is considered medically necessary when ALL of the following clinical criteria are met:

    Initial intraosseous BVNA eligibility

    • Pain duration and impact: The member has a diagnosis and documentation of low back pain for at least 6 months that causes functional deficit measured on a pain or disability scale.at least 6 months
    • Pain distribution: Pain is localized primarily to the lumbar spine without predominant radicular symptoms.
    • Conservative therapy failure or inability to complete active therapy: The member has documented failure of at least 6 weeks of active and inactive conservative therapy within the past 6 months OR was unable to complete active conservative therapy because of contraindication, increased pain, or intolerance.at least 6 weeks within the past 6 months
    • MRI findings: MRI demonstrates Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1, corresponding to the member’s pain.L3 through S1; Type 1 or Type 2 Modic changes
    • Exclusion of other pain generators: Clinical evaluation demonstrates that the member’s pain is not primarily attributable to another pain generator, such as symptomatic facet arthropathy, symptomatic lumbar spinal stenosis, or sacroiliac joint dysfunction.
    • FDA-approved device: The device is FDA-approved, such as the Intracept System.

    • No contraindications

      • Cardiopulmonary status: No severe cardiac or pulmonary compromise.
      • Infection status: No active systemic infection or localized infection in the area to be treated.
      • Pregnancy status: The member is not currently pregnant.
      • Skeletal maturity: The member is skeletally mature.
      • Electronic device safety: The member does not have an implantable electronic device that cannot be safely managed or deactivated during the procedure, such as a pacemaker or defibrillator.

    Repeat or additional intraosseous BVNA is not considered medically necessary.

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

    Intraosseous BVNA is not medically necessary for indications other than the coverage criteria stated in this policy.

    Repeat or additional intraosseous BVNA is not 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 medically necessary and therefore will not be reimbursed.

    BVNA is not medically necessary when any listed contraindication is present, including severe cardiac or pulmonary compromise, active systemic or localized infection in the treatment area, current pregnancy, skeletal immaturity, an implantable electronic device that cannot be safely managed or deactivated, or spinal abnormality or anatomy that prevents safe access to the ablation site. Coverage is also limited to the stated policy criteria; BVNA requested for other indications is not medically necessary.

    Coverage-Critical Clinical Parameters

    Low Back Pain Duration
    Required durationAt least 6 months
    Clinical conditionLow back pain
    Required impactCauses functional deficit measured on a pain or disability scale
    Conservative Therapy Requirement
    Required durationAt least 6 weeks within the past 6 months
    Therapy typesActive and inactive conservative therapy
    Alternative pathwayInability to complete active therapy because of contraindication, increased pain, or intolerance

    Documentation and Billing Requirements

    Documentation Required

    Document pain duration and functional impact

    Document low back pain for at least 6 months, the associated functional deficit measured with a pain or disability scale, and pain primarily localized to the lumbar spine without predominant radicular symptoms.

    Documentation Required

    Document conservative treatment history

    Document at least 6 weeks of active and inactive conservative therapy within the past 6 months. If active therapy could not be completed, document that the reason was 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, devices, TENS, and pharmacotherapy.
    Documentation Required

    Clinical Background

    Chronic low back pain may arise from degeneration of the vertebral endplates, producing vertebrogenic pain associated with Modic changes on MRI. Modic changes are vertebral bone-marrow signal-intensity changes commonly associated with degenerative disc disease. BVNA is an image-guided radiofrequency procedure that thermally ablates the basivertebral nerve within the vertebral body to interrupt pain signaling from the vertebral endplates.

    Policy Definitions

    Chronic Low Back Pain
    DefinitionPersistent pain in the lumbar region
    DurationMore than 12 weeks
    Anatomic regionLumbar region
    Conservative Therapy
    DefinitionA multimodality plan of care
    Required componentsBoth active and inactive conservative therapies
    PurposeTreatment of chronic low back pain

    Required Conservative Therapy

    Conservative Treatment Requirements

    Document failure of multimodal conservative therapy, or document why active therapy could not be completed. The requirement is met when either of the following applies:

    ONE of

    • Documented conservative therapy: The medical record documents at least 6 weeks of both active and inactive conservative therapy within the past 6 months.at least 6 weeks 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, devices, TENS, and pharmacotherapy.

    • Unable to complete active therapy: The member was unable to complete active conservative therapy because of a contraindication, increased pain, or intolerance.

    MRI and Modic Change Requirements

    Prior Authorization

    Obtain MRI before BVNA

    MRI is required to establish qualifying findings before intraosseous basivertebral nerve ablation. The MRI must demonstrate Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1 that correspond to the member’s pain.

    Noncovered Services and Indications

    The following are not covered: repeat or additional intraosseous BVNA; monitored anesthesia and conscious sedation during intraosseous BVNA; and intraosseous BVNA for indications outside the policy's stated coverage criteria.

    Policy Summary
    PayerHap CareSource MI Coordinated Health
    PolicyIntraosseous Basivertebral Nerve Ablation
    Policy CodePolicy MM-1832
    Change TypeClinical content update
    Effective DateNovember 1, 2026
    Last ReviewAug 12, 2026
    Next Review DateN/A
    Key ActionSubmit MRI documentation demonstrating Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1 that correspond to the member's pain.
    SourceLink
    On This Page
    BVNA Medical Necessity and Coverage LimitsCoverage-Critical Clinical ParametersDocumentation and Billing RequirementsClinical BackgroundPolicy DefinitionsRequired Conservative TherapyMRI and Modic Change RequirementsNoncovered Services and Indications
    Eligible Vertebral Levels
    Eligible rangeL3 through S1
    Imaging siteOne or more vertebral endplates
    Clinical correlationFindings must correspond to the member's pain
    MRI Modic Findings
    Required findingsType 1 or Type 2 Modic changes
    Imaging modalityMRI
    Finding locationOne or more vertebral endplates

    Submit qualifying MRI findings

    Submit MRI documentation demonstrating Type 1 or Type 2 Modic changes at one or more vertebral endplates from L3 through S1 that correspond to the member’s pain.

    Documentation Required

    Exclude other primary pain generators

    Document clinical evaluation showing that the pain is not primarily attributable to another pain generator.

    • Evaluate for symptomatic facet arthropathy.
    • Evaluate for symptomatic lumbar spinal stenosis.
    • Evaluate for sacroiliac joint dysfunction.
    Documentation Required

    Document device approval and safety

    Document use of an FDA-approved device, such as the Intracept System, and confirm that the member has none of the listed contraindications.

    Denial Risk

    Repeat or additional BVNA is not covered

    Do not request repeat or additional intraosseous BVNA as medically necessary. The policy states that it has not been adequately studied in peer-reviewed medical literature.

    Billing Rule

    Anesthesia and conscious sedation will not be reimbursed

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

    Denial Risk

    Screen for contraindications

    BVNA is not medically necessary when any listed contraindication is present.

    • Severe cardiac or pulmonary compromise.
    • Active systemic infection or localized infection in the area to be treated.
    • Current pregnancy.
    • Skeletal immaturity.
    • An implantable electronic device that cannot be safely managed or deactivated during the procedure, such as a pacemaker or defibrillator.
    • A spinal abnormality or anatomic consideration that may preclude safe access to the ablation site, such as malignancy or a sensitive structure not intended to be ablated.
    Denial Risk

    Use BVNA only for covered indications

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

    Active Conservative Therapies
    PurposeStrengthen muscle groups and target key spinal structures
    Therapy examplesPhysical therapy and occupational therapy
    Other qualifying interventionsPhysician-supervised home exercise program and/or chiropractic care
    Home Exercise Program
    Required elementsSpecific goals, frequency, and expected duration
    ReassessmentClearly defined timeframe, such as 6–12 weeks
    ContinuationMust be supported by documented clinical progress
    Inactive Conservative Therapies
    DefinitionPassive activities that aid in treating pain symptoms
    ExamplesRest, ice, heat, medical devices, and TENS
    PharmacotherapyPrescription or over-the-counter NSAIDs or acetaminophen
    Modic Changes
    DefinitionVertebral bone marrow signal-intensity changes observable on MRI
    Common associationDegenerative disc disease
    Imaging modalityMRI
    Modic Change Type 1
    T1-weighted imagesHypointense signals
    T2-weighted imagesHyperintense signals
    ClassificationModic Change Type 1
    Modic Change Type 2
    T1-weighted imagesHyperintense signal intensities
    T2-weighted imagesHyperintense signal intensities
    ClassificationModic Change Type 2
    Modic Change Type 3
    T1-weighted imagesHypointense signal intensities
    T2-weighted imagesHypointense signal intensities
    ClassificationModic Change Type 3