ModifiedUnitedHealthcarePolicy CS001ID.B

Ablative Treatment for Spinal Pain (for Idaho Only)

Governs coverage and medical necessity determinations for various ablative procedures for spinal pain for members in the state of Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Idaho Only)

Policy CodePolicy CS001ID.B

Change TypeClarification: Idaho Medicaid fee‑schedule codes noteddefinitions and evidence sections updated

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify state/plan-specific coverage and prior-authorization requirements before billing, especially for CPT codes 64625, 64628, and 64629.

SourceLink

POLICY UPDATE CHANGES

Removed definition of 'Conventional (Thermal) Radiofrequency Ablation'.

Added notation that CPT codes 64625, 64628, and 64629 are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program.

Updated Clinical Evidence and References sections to reflect the most current information.

Idaho onlyjurisdiction

evidence insufficientunproven techniques

64%BVNA ≥50% pain reduction

6 monthsrepeat RFA interval

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225SMART trial randomized

Coverage Criteria and Evidence Summary

Not medically necessary / Unproven

Techniques considered unproven and not medically necessary due to insufficient evidence:

Unproven Ablative Techniques: The following facet joint nerve ablation techniques are unproven and not medically necessary due to insufficient evidence of efficacy: Pulsed Radiofrequency Ablation of the facet nerves of the cervical, thoracic, or lumbar region, sacral nerve root, or dorsal root ganglion; Endoscopic radiofrequency ablation/endoscopic rhizotomy; Cryoablation (cryodenervation, cryoneurolysis, cryosurgery, or cryoanesthesia); Cooled Radiofrequency Ablation; Chemical ablation (including, but not limited to, alcohol, phenol, or sodium morrhuate); Laser ablation (including pulsed, continuous, or low level).

supported by policy statement and evidence summaries

Other specific noncovered indications: Ablation for treating sacroiliac pain is unproven and not medically necessary due to insufficient evidence of efficacy. Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept) for the treatment of spinal pain is unproven and not medically necessary due to insufficient evidence of efficacy.

explicitly listed in coverage rationale

BVNA — evidence and limitations

Evidence summary for intraosseous basivertebral nerve ablation (BVNA/Intracept):

BVNA evidence synthesis: Randomized and prospective trials demonstrate clinically meaningful improvements in ODI and pain scores versus standard care and versus sham in some analyses; pooled and long-term follow-up analyses report sustained improvements and reductions in downstream conservative care and opioid use through 3–5 years. However, trial limitations include industry sponsorship, open-label designs, high crossover from control to treatment in some trials, limited safety data beyond early follow-up, and the need for additional high-quality, independent RCTs to confirm comparative effectiveness.Modic type 1 or 2

See SMART (Fischgrund), Khalil, pooled analyses (Smuck, McCormick) and Hayes assessment for specifics.

CRFA — evidence and limitations

Evidence summary for cooled radiofrequency ablation (CRFA) for facet and sacroiliac joint pain:

CRFA findings: Small randomized trials and observational studies report approximately 50% responder rates for medial branch CRFA and some studies suggest greater or more durable analgesia for CRFA versus conventional RFA for SIJ pain; however, differences are often not statistically significant, evidence beyond 6–12 months is limited, and studies are constrained by small sample sizes and observational designs, indicating insufficient evidence to establish definitive long-term safety and efficacy.>=50% responder rates reported in small RCTs

McCormick RCT, Cohen multicenter SIJ RCT, Tinnirello retrospective cohort, and systematic reviews summarized.

Chemical and laser ablation — insufficient evidence

Evidence summary for chemical and laser ablation:

Chemical/laser ablation: Available studies for chemical ablation (e.g., alcohol) and laser ablation are small, heterogeneous, and primarily observational or limited RCTs; current evidence is insufficient to establish their safety and efficacy for treating spinal pain. Well-designed randomized controlled trials with adequate sample sizes and long-term follow-up are needed.

Joo randomized study and small case series for laser provide limited and inconclusive data.

Covered with criteria / Candidate selection and repeat-procedure logic

Coverage considerations and clinical criteria referenced from guideline and trial evidence

Basivertebral nerve (Intracept) candidate criteria: Patients considered for BVNA typically have chronic low back pain of vertebrogenic origin with Modic type 1 or 2 changes of the treated vertebral bodies (L3–S1) and have failed non‑surgical treatment. Randomized trials enrolled patients meeting these imaging and duration criteria and showed improvements in ODI and pain versus sham or standard care at early follow-up, though limitations (crossover, sponsorship, limited safety follow-up) affect longer-term comparative inference.Modic type 1 or 2

Derived from SMART/INTRACEPT and other BVNA trials and pooled analyses.

Medial branch RFA candidate criteria: Patients with pain judged to originate from structures supplied by the medial branch nerve should have a positive diagnostic medial branch block (prognostic block) prior to RFA. Repeat procedures are generally limited to those with documented meaningful initial benefit (commonly defined as ≥50% pain relief), and candidates for repeat RFA should demonstrate sustained relief before re-treatment.>=50% pain relief

Consistent with ASIPP, ASRA guidance and trial selection paradigms.

The policy designates multiple ablative approaches as unproven and not medically necessary because the available evidence is insufficient to establish safety and efficacy. Techniques explicitly listed include pulsed radiofrequency ablation of facet nerves/DRG, endoscopic radiofrequency ablation/endoscopic rhizotomy, cryoablation, and cooled radiofrequency ablation. The policy also states that ablation for treating sacroiliac pain is unproven and not medically necessary. These listings reflect limited trial data, small sample sizes, and inconsistency in reported outcomes across studies.

The policy concludes that current evidence for chemical ablation (for example, alcohol, phenol, sodium morrhatuate) and laser ablation is insufficient to establish safety and efficacy for spinal pain. Available studies are small, often nonrandomized or case series, and subject to short follow-up and methodological limitations; the document therefore calls for well-designed randomized controlled trials with larger sample sizes and longer-term outcomes to support these modalities.

FDA device listings and clearances are provided in the policy for informational purposes only; the document emphasizes that FDA approval alone is not a basis for coverage. Separately, the policy notes an operational billing issue for Idaho Medicaid: CPT codes 64625, 64628, and 64629 are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered, and providers should consult the Idaho Medicaid Provider Handbook for non-covered services.

The policy enumerates modalities considered unproven / not medically necessary: pulsed radiofrequency ablation (facet nerves/DRG), endoscopic RFA/endoscopic rhizotomy, cryoablation, cooled radiofrequency ablation, chemical ablation (e.g., alcohol, phenol, sodium morrhuate), and laser ablation (pulsed, continuous, or low level). These techniques are grouped together based on the insufficiency of high-quality evidence demonstrating clinically meaningful benefit.

A Hayes technology assessment (2021, updated 2025) reviewed clinical studies of the Intracept intraosseous basivertebral nerve ablation system and concluded there is only minimal support in the clinical evidence. The review highlighted limitations including trial quality concerns, inconsistent demonstration of superiority over sham, and the need for more robust randomized data to confirm benefits and safety.

The policy describes limitations of the randomized BVNA trials: the sham-controlled SMART (Intracept) trial enrolled 225 patients and showed short-term advantages in ODI and responder rates, but open-label extensions, manufacturer sponsorship, high crossover from sham to active treatment, and limited safety data beyond 3 months constrain long-term comparative interpretation. The document does not include an explicit additional not‑medically‑necessary statement beyond summarizing these trial limitations and associated assessments.

Procedure and Diagnosis Codes (Reference)

Applicable procedure codes (reference)CPT

22899	Unlisted procedure, spine [when used to report the Intracept procedure or cooled radiofrequency ablation]
27299	Unlisted procedure, pelvis or hip joint
64625	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography)
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)
64999	Unlisted procedure, nervous system

Not on Idaho Medicaid Fee Schedule / billing notesCPT

64625	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) — not on the State of Idaho Medicaid Fee Schedule
64628	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral — not on the State of Idaho Medicaid Fee Schedule
64629	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral — not on the State of Idaho Medicaid Fee Schedule

Responder definition (study)

Responder definition (study)Responder defined as ≥ 50% reduction in Numeric Rating Scale (NRS) pain at 6 months (primary outcome in McCormick CRFA RCT).

Alternate responder metric reportedStudies also report responder analyses using ≥15-point or ≥30% reductions in ODI and other thresholds for functional improvement.

Context of useUsed as the primary efficacy endpoint in randomized trials comparing CRFA and traditional RFA for medial branch/facet pain.

Pain severity threshold — NICE recommendation

Pain severity threshold for referralModerate or severe localized back pain rated ≥5 on the Visual Analog Scale (VAS) or equivalent at time of referral.

Prerequisites

Provider Actions, Prior Authorization, and Documentation

Denial Risk

Procedures Designated Unproven / Not Medically Necessary

The following procedures and techniques are designated as unproven and not medically necessary due to insufficient evidence of efficacy. Providers should not expect routine coverage for these modalities and should document clinical rationale if requested for exception review.

Pulsed radiofrequency ablation of the facet nerves (cervical, thoracic, lumbar), sacral nerve root, or dorsal root ganglion
Endoscopic radiofrequency ablation/endoscopic rhizotomy
Cryoablation (cryo-denervation, cryoneurolysis, cryosurgery, cryoanesthesia)
Cooled radiofrequency ablation (CRFA) — note: CRFA for sacroiliac joint pain is discussed in the evidence summary but remains unproven in this policy section
Chemical ablation (e.g., alcohol, phenol, sodium morrhuate)
Laser ablation (pulsed, continuous, low-level)
Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept ® ) for vertebrogenic pain

Conservative Care and Diagnostic Block Requirements

Documented short-term benefit from diagnostic SIJ injection and prognostic lateral branch blocks (per study protocols)

Study protocols selecting patients for ablation frequently required documented short-term benefit from diagnostic SIJ injection and prognostic lateral branch blocks:

SIJ diagnostic requirement (per trials): Randomized trials of CRFA for sacroiliac joint pain required that participants obtain short-term benefit from diagnostic SIJ injections and prognostic lateral branch blocks prior to randomization, and documented block response was used to select candidates for treatment.

Cohen et al. CRFA SIJ RCT required positive diagnostic SIJ injections and prognostic lateral branch blocks.

Conservative therapy attempts and prior interventions should be documented prior to BVNA consideration

Evidence and trial populations imply prior conservative therapy and prior interventions should be documented before considering BVNA:

Prior conservative therapy for BVNA: BVNA trials enrolled patients with refractory chronic low back pain (minimum 6 months) who had failed non-surgical treatments; many participants had prior spinal injections and conservative care. Documentation of prior conservative therapy attempts and prior interventions (including prior injections) is therefore expected before BVNA consideration.

Procedure Frequency and Repeat Treatment Limits

Medial branch neurotomy / facet joint RFA frequency

Minimum interval per regionMedial branch neurotomy / facet joint RFA should not be performed more frequently than every 6 months per treated region.

Maximum frequency per yearMaximum of two procedures per year per region when ≥50% relief is obtained and sustained for approximately 5–6 months.

Multi-region timingIf multiple regions are treated, therapeutic frequency should remain at intervals of at least 6 months per region; simultaneous treatment of multiple regions is suggested when safe.

Medial branch / facet RFA — frequency limits

Annual procedure limitNo more than two RFA procedures per year for the same region (repeat procedures for recurrence should be limited to patients with a good initial outcome).

Interval requirement

Imaging and Diagnostic Test Requirements

Documentation Required

Image guidance required for certain ablative procedures

When performing image-guided ablative procedures, studies and protocols reported use of fluoroscopy or CT guidance; document use of appropriate image guidance (fluoroscopy or CT) for RFA or cryoablation procedures where applicable.

Trials and case series used fluoroscopy or CT for needle/electrode placement for CRFA and cryorhizotomy.

Documentation Required

BVNA / Intracept — MRI showing Modic type 1 or 2 required in trials

BVNA/Intracept trial inclusion required MRI demonstrating Modic type 1 or 2 changes of the treated vertebral bodies; document MRI findings showing Modic type 1 or 2 changes when considering BVNA.

Modic type 1 or 2 changes between L3 and S1 were required in key BVNA trials.

Not Covered / Excluded Procedures

Procedures explicitly listed as not covered / not medically necessary in the policy include pulsed RFA of facet nerves/DRG, endoscopic RFA/endoscopic rhizotomy, and cryoablation for spinal pain. These modalities are called out because available evidence does not adequately demonstrate consistent clinical benefit.

For clarity and visibility throughout the document, the policy reiterates that pulsed radiofrequency ablation, endoscopic RFA/endoscopic rhizotomy, and cryoablation are designated as unproven and not medically necessary for spinal pain.

The policy again lists pulsed RFA, endoscopic RFA/endoscopic rhizotomy, and cryoablation among procedures considered unproven to ensure consistent coverage messaging across sections.

This policy restates that pulsed RFA of facet nerves/DRG, endoscopic rhizotomy, and cryoablation lack sufficient evidence and are treated as not medically necessary for spinal pain indications.

To maintain clear guidance, the document repeats that pulsed RFA, endoscopic RFA/endoscopic rhizotomy, and cryoablation are considered unproven and not medically necessary.

The list of noncovered ablative techniques—pulsed RFA, endoscopic RFA, and cryoablation—is reiterated to aid benefit adjudication and prior‑authorization review.

Definitions and Terminology

Cooled Radiofrequency Ablation — definition

DefinitionCooled radiofrequency ablation (CRFA) is the application of continuous high-frequency electrical current using water-cooled electrodes/probes to ablate nerve tissue, intended to create larger lesion sizes compared with conventional probes.

Clinical role notedCRFA has been studied for medial branch/facet and sacroiliac joint pain in randomized and observational studies showing roughly 50% responder rates in some trials, though evidence is limited.

Technique distinctionCRFA uses active cooling of the probe to allow for longer energy delivery and larger lesions versus conventional thermal RFA probes.

Pulsed Radiofrequency Ablation — definition

DefinitionPulsed radiofrequency ablation (pulsed RFA) delivers intermittent short bursts of energy rather than continuous thermal energy, using probe temperatures typically around 42–45 °C.

Policy Revision History

2026-05-01policy_revisionLatest

Removed the definition of 'Conventional (Thermal) Radiofrequency Ablation' and added a notation that CPT codes 64625, 64628, and 64629 are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program; Clinical Evidence and References sections were also updated.

Background and Scope

Ablative procedures for spinal pain aim to disrupt nociceptive pathways by destroying or altering nerve tissue. Techniques reviewed in this policy include thermal radiofrequency approaches (conventional medial branch RFA), pulsed RFA (delivering intermittent bursts of energy at lower probe temperatures), cooled RFA (using water‑cooled probes to create larger lesions), cryoablation, chemical and laser neurolytic methods, endoscopic approaches, and intraosseous basivertebral nerve ablation (Intracept). The evidence base across these modalities is heterogeneous and limited by small studies, variable techniques, and inconsistent long‑term outcome data.

Policy Summary

PayerUnitedHealthcare

PolicyAblative Treatment for Spinal Pain (for Idaho Only)

Policy CodePolicy CS001ID.B

Change TypeClarification: Idaho Medicaid fee‑schedule codes noteddefinitions and evidence sections updated

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify state/plan-specific coverage and prior-authorization requirements before billing, especially for CPT codes 64625, 64628, and 64629.

SourceLink

On This Page

Repeat RFA frequency logic: Repeat RFA should be reserved for recurrent pain after an initial successful RFA and is suggested to occur no more than twice per year for the same region, with intervals of at least 6 months between procedures per region.<=2 times/year; >=6 months per region

ASIPP and ASRA recommendations; NASS reports durable relief for at least 6 months.

Non-surgical treatment must have failed and the main source of pain should be thought to arise from structures supplied by the medial branch nerve.

Diagnostic requirementReferral for radiofrequency denervation should follow a positive response to a diagnostic medial branch block.

Denial Risk

Evidence Limitations and Denial Risk

Clinical evidence for several treatments (notably intraosseous basivertebral nerve ablation and cooled CRFA for SIJ pain) is limited, of variable quality, or has methodological concerns (small trials, short follow-up, manufacturer sponsorship, crossover/sham issues). Insufficient or low-quality evidence may increase the likelihood of claim denial. When submitting for prior authorization or appeals, include robust documentation of prior conservative care, diagnostic testing, and objective outcome measures.

Insufficient/limited evidence and study limitations (risk of bias, short follow-up, open-label designs) may lead to noncoverage determinations
Provide complete supporting documentation (see Documentation callout) if requesting coverage for procedures with limited evidence

Prior Authorization

CRFA / SIJ — Diagnostic and Selection Requirements

For sacroiliac joint (SIJ) procedures such as cooled radiofrequency ablation (CRFA) and other RFA techniques, many clinical trials required prior diagnostic injections and prognostic lateral branch or medial branch blocks to select likely responders. Prior authorization requests should explicitly document these diagnostic steps and the patient’s response.

Document a positive short-term diagnostic SIJ injection and/or prognostic lateral branch blocks demonstrating clinically meaningful temporary pain relief prior to CRFA consideration
Include details of the diagnostic blocks (agent used, percent pain relief, duration of relief, date performed)

Documentation Required

Conservative Therapy and Outcome Measurement Requirements

Trials of CRFA for SIJ pain and many BVNA studies required prior conservative therapies and documented functional outcome measures at baseline and follow-up. Prior authorization should confirm that conservative management was attempted and that validated baseline/outcome measures are available.

Document trials of conservative care (e.g., pharmacotherapy, physical therapy, targeted injections, activity modification) and dates/duration of therapies
Provide validated baseline and follow-up outcome measures (e.g., ODI, NRS/NPS, SF-36, EuroQoL-5) used in trials

Billing Rule

Coding and Prior Authorization Reference

CPT/procedure codes are provided for reference only. Inclusion does not guarantee coverage; providers must verify state- and plan-specific coverage. Note that certain codes are not on the Idaho Medicaid Fee Schedule and may be denied for Idaho Medicaid members.

Codes of interest: 64625 (RFA, nerves innervating the sacroiliac joint) — may not be covered by Idaho Medicaid
64628, 64629 (thermal destruction of intraosseous basivertebral nerve) — may not be covered by Idaho Medicaid
Unlisted spine/pelvis codes: 22899, 27299, 64999
Providers must verify coverage and prior authorization requirements with the member’s specific plan and state rules

Prior Authorization

Procedure Frequency, Repeat Treatments, and Prior Authorization Considerations

Professional society guidance and consensus statements recommend diagnostic/prognostic blocks and limits on repeat procedures. Prior authorization should address procedure frequency and documented response thresholds when repeat interventions are requested.

ASIPP: suggest interval ≥ 6 months between repeat medial branch neurotomies per region, and require ≥50% relief for 5–6 months to consider repeat treatment
ASRA: repeat RFA recommended for patients with ≥50% relief at 3 months; generally no more than two procedures per year
NICE: only perform radiofrequency denervation after positive diagnostic medial branch block; require moderate-severe localized back pain and failure of non-surgical treatment

Pooled analyses and trial inclusion criteria (Khalil, SMART, pooled studies) describe refractory populations with prior conservative care.

Prior non-surgical therapy and positive diagnostic/prognostic block prior to RFA — required steps before proceeding

Guidelines and trial selection criteria require prior non-surgical therapy and diagnostic/prognostic blocks before proceeding to RFA:

Prior non-surgical therapy requirement: Non-surgical treatments should have been tried without adequate relief before referral for radiofrequency denervation; guideline sources recommend conservative therapy attempts prior to RFA referral.

NICE recommends non-surgical treatment prior to referral; ASIPP/ASRA guidance aligns with this approach.

Diagnostic/prognostic block requirement: Perform diagnostic medial branch blocks (or other appropriate prognostic blocks such as SIJ injections and lateral branch blocks for SIJ procedures) and document a positive response prior to proceeding with RFA.Positive diagnostic block (commonly >=50% relief)

ASRA and ASIPP recommend medial branch blocks as prognostic screening before lumbar facet RFA; CRFA SIJ trials required diagnostic blocks.

Repeat RFA candidacy: Repeat RFA is indicated only for recurrence in patients who had a good outcome from the prior RFA, typically defined as at least 50% pain relief at about 3 months; repeat procedures should follow society-recommended frequency limits.>=50% relief; intervals >=6 months

ASRA and ASIPP recommend repeating no more than twice per year with at least 6 months between procedures per region.

Intervals of at least 6 months are recommended between medial branch neurotomy procedures for each region treated.

Repeat-criteria tie-inRepeat RFA is recommended only for patients who had at least ~50% pain relief at 3 months from the prior procedure (per consensus guidance).

Note

Radiofrequency denervation — imaging not required (where applicable)

Guidance (NICE) states imaging is not required as a prerequisite for radiofrequency denervation; do not rely on MRI as a mandatory prerequisite for routine medial branch RFA unless trial- or payor-specific criteria require it.

NICE: Do not offer imaging as a prerequisite for radiofrequency denervation for suspected facet joint pain.

Documentation Required

Basivertebral nerve (Intracept) ablation — Modic changes on MRI required in trials

Basivertebral nerve (Intracept) ablation in trials required presence of Modic type 1 or 2 changes on MRI of the treated vertebral bodies; document these MRI findings to support BVNA requests.

SMART and other BVNA trials enrolled only patients with Modic type 1 or 2 changes on MRI.

For easy reference in denial and coverage determinations, the policy repeats that pulsed radiofrequency ablation, endoscopic RFA, and cryoablation are designated as not medically necessary.

The policy continues to list pulsed RFA, endoscopic RFA/endoscopic rhizotomy, and cryoablation as unproven, supporting uniform application across claims and utilization management.

This is an additional restatement for policy readers: pulsed RFA of facet nerves/DRG, endoscopic rhizotomy, and cryoablation are considered unproven/not medically necessary.

Operational billing information notes that CPT codes 64625, 64628, and 64629 are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid. Providers should verify state/plan coverage and prior‑authorization requirements before billing these codes.

Pulsed RFA is designed to modulate nerve function without producing the same degree of thermal neurodestruction as continuous thermal RFA.

Evidence/coverage statusThis policy lists pulsed RFA of facet nerves/DRG as unproven and not medically necessary due to insufficient evidence of efficacy.

Intracept / BVNA — definition and target indication

DefinitionIntracept (basivertebral nerve ablation, BVNA) is an intraosseous radiofrequency procedure that targets the basivertebral nerve within the vertebral body to treat vertebrogenic chronic low back pain.

Target populationTypically applied to patients with chronic low back pain and Modic type 1 or 2 changes of the treated vertebral bodies (commonly between L3 and S1).

Trial evidence summaryRandomized sham-controlled SMART trial (n=225) demonstrated greater ODI and pain improvements at 3 months versus sham, with sustained improvements on open-label follow-up but with crossover and follow-up limitations.

Cooled radiofrequency ablation (CRFA) — definition (alternate)

Alternate CRFA descriptionCRFA: continuous high-frequency electrical current applied with water-cooled electrodes/probes to ablate nerve tissue; cooling permits larger lesion creation for denervation of medial or lateral branch nerves.

Used forStudied for denervation of medial branch nerves (facet) and lateral branch nerves (sacroiliac joint) to produce analgesia.

Evidence caveatRandomized trials and meta-analyses exist but are limited by small sizes and lack of consistent comparison groups; higher-quality RCTs are needed.

Intracept procedure / basivertebral nerve (BVN) ablation

Procedure definitionThe Intracept procedure (BVN ablation) involves intraosseous access to the vertebral body and delivery of thermal radiofrequency energy to ablate the basivertebral nerve.

Relation to Modic changesClinical trials enrolled patients with Modic type 1 or 2 vertebral endplate changes; presence of these Modic changes was an inclusion requirement in randomized studies.

Outcomes reportedTrials reported clinically meaningful improvements in ODI and pain at 3 months with sustained benefit in open-label follow-up, but limitations include manufacturer sponsorship and high crossover rates.

Medial branch RFA — definition and usual diagnostic pathway

DefinitionMedial branch radiofrequency ablation (medial branch RFA) is thermal RFA targeting the medial branch nerves that innervate the zygapophyseal (facet) joints to relieve facet-mediated spinal pain.

Diagnostic pathwayTypically performed after a positive diagnostic medial branch block (prognostic block) to confirm the facet joint as the pain source before proceeding to RFA.

Repeat-procedure guidanceGuidelines recommend repeating RFA only for patients with a good initial outcome (commonly defined as ≥50% pain relief at ~3 months) and limiting repeat procedures to about two times per year with ≥6-month intervals per region.