CurrentUnivera HealthcarePolicy 7.01.124

Intraosseous Basivertebral Nerve Ablation for Child Health Plus (CHP) and Essential Plan (EP) Members

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Medical-necessity criteria for thermal ablation of the intraosseous basivertebral nerve in Child Health Plus and Essential Plan members, including age, pain characteristics, MRI findings, conservative treatment, and procedural imaging requirements.

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CurrentUnivera HealthcarePolicy 7.01.124

Intraosseous Basivertebral Nerve Ablation for Child Health Plus (CHP) and Essential Plan (EP) Members

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Policy Summary

PayerUnivera Healthcare

PolicyIntraosseous Basivertebral Nerve Ablation for Child Health Plus (CHP) and Essential Plan (EP) Members

Policy CodePolicy 7.01.124

Change TypeAdministrative and editorial revisionno material clinical or coverage change

Effective DateJanuary 1, 2027

Next Review DateSeptember 1, 2027

Key ActionDocument at least 6 months of failed or not tolerated nonsurgical conservative treatment, including one non-pharmacologic and one pharmacologic or interventional option.

SourceLink

POLICY UPDATE CHANGES

The policy was edited with reformatting and language updates, while the intent remained unchanged.

18+ yearsMinimum member age

6 monthsPain duration

L3-S1Eligible vertebral levels

12 monthsMaximum MRI age

T-score ≤ -2.5Osteoporosis threshold

9ICD-10 codes listed

Medical Necessity and Exclusions

Medical Necessity Criteria

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

ALL of the following

Individual is 18 years of age or older.>= 18 years
Pain meets ALL of the following
- The predominant symptom is axial low back pain.
- Pain causes functional impairment, such as reduced mobility or impaired activities of daily living.
- There has been a minimum of 6 months of low back pain.>= 6 months
- Documented clinical findings support a vertebrogenic etiology, such as deep midline pain aggravated by bending, prolonged standing, or sitting.
MRI performed within the previous 12 months documents Modic Type 1 and/or Type 2 endplate changes at a minimum of one vertebral level from L3 to S1.At least 1 level from L3-S1; MRI within 12 months
At least 6 months of non-surgical conservative treatment failed to improve pain or was not tolerated, including BOTH of the following
- Non-pharmacologic management includes at least ONE of the following
  - Acupuncture.
  - Chiropractic treatment.
  - Cognitive behavioral therapy.
  - Supervised physical therapy (PT).
- Pharmacologic/interventional management includes at least ONE of the following
  - Interventional pain management with epidural steroid injections (ESI) or facet-based interventions.
The procedure will be performed using fluoroscopic or computed tomography (CT) guidance.

Contraindications and Not Medically Necessary

Thermal ablation of the intraosseous basivertebral nerve (BVN) is contraindicated and not medically necessary if ANY of the following conditions apply:

ANY of the following

Active infection, local or systemic.
Bleeding or clotting disorder.
Osteoporosis.T-score <= -2.5
Spinal malignancy.
Trauma or compression fracture involving the intended treatment level.

Coverage requires documented clinical support for a vertebrogenic pain source, qualifying Modic Type 1 or Type 2 changes on recent MRI, and failure or intolerance of the specified conservative treatment components.

The procedure must be performed with fluoroscopic or CT guidance.

The complete exclusion logic is governed by the ANY-of contraindication criteria. Any listed alternative pain generator, clinical condition, implanted device, pregnancy, age-related limitation, or other exclusion makes the procedure not medically necessary.

Active local or systemic infection is a contraindication and renders thermal ablation of the intraosseous basivertebral nerve not medically necessary.

A bleeding or clotting disorder is an exclusion and renders the procedure not medically necessary.

Osteoporosis is an exclusion when the bone-density T-score is less than or equal to -2.5.

The procedure is not medically necessary when any remaining listed exclusion applies, including spinal malignancy; trauma or compression fracture at the intended treatment level; vertebral fragility fracture; prior BVN ablation or spinal surgery at the requested level; an alternative imaging-identified cause of pain; an implanted electronic device; Modic Type 3 changes; pregnancy; radicular or compressive primary symptoms; severe cardiac or pulmonary impairment; or skeletal immaturity.

The primary symptom exclusions include lumbar radiculopathy, nerve compression or impingement (including stenosis or HNP), neurogenic claudication, and radicular pain.

Coding and Reference Thresholds

CPT CodesCPT

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)

ICD-10 CodesICD-10

M42.16	Adult osteochondrosis of spine, lumbar region.
M42.17	Adult osteochondrosis of spine, lumbosacral region.
M51.36	Other intervertebral disc degeneration, lumbar region.
M51.360	Other intervertebral disc degeneration, lumbar region with discogenic back pain only.
M51.37	Other intervertebral disc degeneration, lumbosacral region.
M51.370	Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only.
M54.50	Low back pain, unspecified.
M54.51	Vertebrogenic low back pain.
M54.59	Other low back pain

Osteoporosis T-score

ConditionOsteoporosis

Qualifying thresholdT-score ≤ -2.5

Policy effectThermal ablation is contraindicated and not medically necessary

Age

ConditionSkeletal immaturity

Exclusion thresholdYounger than 18 years of age

Policy effectThermal ablation is contraindicated and not medically necessary

Documentation and Coverage Actions

Documentation Required

Document pain and functional impairment

Document predominantly axial low back pain causing functional impairment, present for at least 6 months, with clinical findings supporting a vertebrogenic etiology.

Record functional impairment, such as reduced mobility or difficulty with activities of daily living.
Document supporting findings such as deep midline pain aggravated by bending, prolonged standing, or sitting.

Documentation Required

Confirm qualifying MRI findings

Provide MRI documentation from within the previous 12 months showing Modic Type 1 and/or Type 2 endplate changes at at least one vertebral level from L3 through S1.

Identify the qualifying vertebral level or levels.
Confirm that the MRI is no more than 12 months old.

Policy Background

This policy addresses thermal ablation of the intraosseous basivertebral nerve for vertebrogenic axial low back pain. Vertebrogenic pain is chronic axial low back pain arising from damaged vertebral endplates and transmitted through the basivertebral nerve. Coverage is evaluated when MRI identifies qualifying Modic Type 1 and/or Type 2 endplate changes at one or more vertebral levels from L3 through S1; the procedure is performed with fluoroscopic or computed tomography guidance.

Clinical Definitions

Modic Type 1 Changes

MRI findingMRI signal abnormalities involving the vertebral endplates and adjacent bone marrow

Underlying changeVertebral endplate and adjacent bone marrow edema and inflammation

Clinical significanceModic type 1 endplate changes are associated with vertebrogenic pain and may qualify as a treatment finding

Modic Type 2 Changes

MRI findingMRI signal abnormalities involving the vertebral endplates and adjacent bone marrow

Underlying changeFatty replacement of vertebral bone marrow

Clinical significance

Required Conservative Management

At Least Six Months of Nonsurgical Conservative Treatment

Before thermal basivertebral nerve ablation, treatment must include at least 6 months of nonsurgical conservative management with both categories represented:

Minimum duration

ONE or more non-pharmacologic options
- Acupuncture.
- Chiropractic treatment.
- Cognitive behavioral therapy.
- Supervised physical therapy (PT).
ONE or more pharmacologic or interventional options

Imaging and Procedure Requirements

Note

Confirm imaging eligibility

Intraosseous basivertebral nerve thermal ablation requires qualifying imaging: MRI must document Modic Type 1 and/or Type 2 endplate changes at a minimum of one vertebral level from L3 to S1.

Imaging is required for eligibility.
The qualifying MRI must have been performed within the previous 12 months.

Documentation Required

Confirm MRI findings and procedural guidance

Confirm Modic Type 1 and/or Type 2 endplate changes on MRI at one or more levels from L3 through S1. The ablation is an image-guided procedure and must use fluoroscopic or CT guidance.

Modic Type 1 changes reflect marrow edema and inflammation; Modic Type 2 changes reflect fatty replacement of bone marrow.
Procedural imaging may use fluoroscopy or CT.

Not Covered Conditions

Thermal ablation is not covered as medically necessary when there is an active local or systemic infection, bleeding or clotting disorder, or osteoporosis with a T-score ≤ -2.5. It is also not medically necessary when any other listed exclusion is present, including spinal malignancy; trauma or compression fracture at the intended treatment level; vertebral fragility fracture; prior basivertebral nerve ablation or spinal surgery at the requested level; an alternative imaging-defined cause of low back pain; implanted pulse generators or other electronic implants; Modic Type 3 endplate changes; pregnancy; primary lumbar radiculopathy, nerve compression or impingement, neurogenic claudication, or radicular pain; severe cardiac or pulmonary impairment; or skeletal immaturity in an individual younger than 18 years of age.

Policy Summary

PayerUnivera Healthcare

PolicyIntraosseous Basivertebral Nerve Ablation for Child Health Plus (CHP) and Essential Plan (EP) Members

Policy CodePolicy 7.01.124

Change TypeAdministrative and editorial revisionno material clinical or coverage change

Effective DateJanuary 1, 2027

Next Review DateSeptember 1, 2027

Key ActionDocument at least 6 months of failed or not tolerated nonsurgical conservative treatment, including one non-pharmacologic and one pharmacologic or interventional option.

SourceLink

On This Page

Nonsteroidal anti-inflammatory drugs (NSAIDs).

Oral analgesic therapy.

Vertebral fragility fracture.

History of basivertebral nerve ablation at the requested vertebral level.

History of spinal surgery at the requested vertebral level.

Imaging evidence on MRI, CT, or X-ray identifies an alternative cause of low back pain symptoms, such as degenerative scoliosis, disc herniation, lumbar stenosis, or spondylolisthesis.

Implanted pulse generator or other electronic implant, such as a pacemaker, defibrillator, or neurostimulator.

Modic Type 3 (sclerotic) endplate changes.

Primary symptoms include ANY of the following

Lumbar radiculopathy.
Nerve compression or impingement, such as stenosis or herniated nucleus pulposus (HNP).
Neurogenic claudication.
Radicular pain.

Severe cardiac or pulmonary impairment.

Skeletal immaturity (younger than 18 years of age).< 18 years

SMART Trial Chronic Pain Duration

StudySMART trial

Chronic pain duration≥6 months

Pain descriptionChronic isolated lumbar pain

SMART Trial Oswestry Disability Index

StudySMART trial

Oswestry Disability Index≥30

MeasureFunctional disability associated with chronic isolated lumbar pain

SMART Trial Visual Analog Scale

StudySMART trial

Visual Analog Scale≥4

MeasurePain severity in participants with chronic isolated lumbar pain

Common Study Enrollment Oswestry Disability Index

Study populationPublished studies generally enrolled skeletally mature patients

Oswestry Disability Index≥30

Clinical significanceSignificant pain and functional impairment

Common Study Enrollment Visual Analog Scale

Study populationPublished studies generally enrolled skeletally mature patients

Visual Analog Scale≥4 cm

Clinical significanceSignificant pain and functional impairment

Step Therapy

Document six months of conservative treatment

Document at least 6 months of failed or not tolerated non-surgical conservative treatment before thermal basivertebral nerve ablation. The treatment history must include at least one non-pharmacologic option and at least one pharmacologic or interventional option.

Non-pharmacologic options: acupuncture, chiropractic treatment, cognitive behavioral therapy, or supervised physical therapy.
Pharmacologic or interventional options: epidural steroid injections or facet-based interventions, nonsteroidal anti-inflammatory drugs, or oral analgesic therapy.
Document that treatment failed to improve pain or was not tolerated.

Documentation Required

Use fluoroscopic or CT guidance

Document that the procedure will be performed using fluoroscopic or computed tomography (CT) guidance.

Use fluoroscopy or CT for procedural guidance.

Denial Risk

Exclude active infection

Thermal ablation is contraindicated and not medically necessary when the individual has an active local or systemic infection; treatment may therefore be denied.

Screen for active local infection.
Screen for active systemic infection.

Denial Risk

Exclude bleeding or clotting disorders

Thermal ablation is contraindicated and not medically necessary when the individual has a bleeding or clotting disorder; treatment may therefore be denied.

Assess for a bleeding disorder.
Assess for a clotting disorder.

Denial Risk

Check the osteoporosis threshold

Thermal ablation is contraindicated and not medically necessary for osteoporosis with a T-score of ≤ -2.5; treatment may therefore be denied.

Verify the patient’s bone-density findings before requesting treatment.
Do not proceed when the osteoporosis T-score is ≤ -2.5.

Denial Risk

Screen for all contraindications and exclusions

Thermal ablation of the intraosseous basivertebral nerve is contraindicated and not medically necessary when any listed exclusion is present, including the conditions below.

Bleeding or clotting disorder; osteoporosis with T-score ≤ -2.5; spinal malignancy; trauma or compression fracture involving the intended treatment level; or vertebral fragility fracture.
History of basivertebral nerve ablation or spinal surgery at the requested vertebral level.
Imaging evidence of an alternative cause of low back pain, including degenerative scoliosis, disc herniation, lumbar stenosis, or spondylolisthesis.
Implanted pulse generators or other electronic implants, including a pacemaker, defibrillator, or neurostimulator; Modic Type 3 endplate changes; or pregnancy.
Primary lumbar radiculopathy, nerve compression or impingement, neurogenic claudication, or radicular pain.
Severe cardiac or pulmonary impairment or skeletal immaturity, defined as younger than 18 years of age.

Billing Rule

Verify product coverage first

Coverage is dependent on the member’s product contract. If the product does not cover the service, the medical policy criteria do not apply to the benefit.

Verify that the member’s product contract covers the service before applying the medical-necessity criteria.

Modic type 2 endplate changes are associated with vertebrogenic pain and may qualify as a treatment finding

Modic Type 3 Changes

MRI findingMRI signal abnormalities involving the vertebral endplates and adjacent bone marrow

Underlying changeSubchondral bony sclerosis

Policy significanceModic type 3 changes are listed among conditions for which thermal ablation is contraindicated and not medically necessary

Vertebrogenic Pain

Pain typeA subtype of chronic axial low back pain

SourceArises from damaged vertebral endplates

Transmission pathwayPain is transmitted through the basivertebral nerve

Neurogenic Claudication

Typical associationLumbar spinal stenosis

Provoked symptomsLower-extremity, buttock, or back pain, numbness, weakness, or paresthesias brought on by standing or walking

Relief patternSymptoms are relieved by sitting or spinal flexion

Radicular Pain

Pain patternPain radiates from the spine into an upper or lower extremity

DistributionDermatomal distribution

Cause and associated symptomsDue to irritation, inflammation, or compression of a spinal nerve root; may include numbness, tingling, or weakness

Interventional pain management with epidural steroid injections (ESI) or facet-based interventions.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Oral analgesic therapy.

Inadequate Improvement Despite Nonsurgical Conservative Management

Coverage requires inadequate improvement despite nonsurgical conservative management:

Inadequate response to conservative management: The individual has chronic low back pain for at least 6 months and has failed to improve adequately despite at least 6 months of nonsurgical management.At least 6 months of pain and nonsurgical management