Basivertebral nerve ablation is a minimally invasive radiofrequency ablative procedure that is intended toablate or destroy the basivertebral nerve in the vertebral body to reduce chronic low back pain.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Basivertebral nerve ablation from L3 through S1 may be considered medically necessary when ALL of the following criteria have been met:
1. The individual is skeletally mature; AND
2. The individual has chronic low back pain of at least six (6) months duration; AND
3. The individual has failed to respond to at least six (6) months of conservative treatment; AND
4. The individual's MRI demonstrates Modic change one (1) (MC1) or Modic change two (2) (MC2) inat least one (1) vertebral endplate at one (1) or more levels from L3 through S1..
Basivertebral nerve ab;ation is a permanent procedure requiring one treatment. Many members will require multipl levels of treatment in one session. The most common number of levels is three (3). For example: Modic changes at L4-5 and L5-S1 would require ablation of the basivertebral nerve in te L4 veterbral body, the L5 vertebral body and the S1 segment.
Basivertebral nerve ablation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
64628, 64629
M47.816, M47.817, M51.36, M51.37, M54.50, M54.59, M54.51
1. Fischgrund JS, Rhyne A, Macadaeg K, Moore G, et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study. Eur Spine J. 2020;29(8):1925-1934.
2. Fischgrund JS, Rhyne A, Franke J, Sasso R, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: A prospective randomized double-blind sham-controlled multi-center study. Eur Spine J. 2018;27(5):1146-1156.
3. Fischgrund JS, Rhyne A, Franke J, Sasso R, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from a prospective randomized double-blind sham-controlled multicenter study. Int J Spine Surg. 2019;13(2):110-119.
4. Khalil JG, Smuck M, Koreckij T, Keel J, et al; INTRACEPT trial investigators. A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2019;19(10):1620-1632.
5. Smuck M, Khalil J, Barrette K, Hirsch JA, et al; INTRACEPT trial investigators. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12month results. Reg Anesth Pain Med. 2021;46(8):683-693.
6. Markman JD, Rhyne AL, Sasso RC, Patel AA, et al. Association between opioid use and patient-reported outcomes in a randomized trial evaluating basivertebral nerve ablation for the relief of chronic low back pain. 2020;86(3):343-347.
7. Truumees E, Macadaeg K, Pena E, Arbuckle J 2nd, et al. A prospective, openlabel, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Eur Spine J. 2019;28(7):1594-1602.
8. Urits I, Noor N, Johal AS, Leider J, et al. Basivertebral nerve ablation for the treatment of vertebrogenic pain. Pain Ther. 2021;10(1):39-53.
9. Tieppo Francio V, Sayed D. Basivertebral nerve ablation. 2021. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.
10. De Vivo AE, D'Agostino G, D'Anna G, Al Qatami H, et al. Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain. 2021;63(5):809-815.
11. Kim HS, Adsul N, Yudoyono F, Paudel B, et al. Transforaminal epiduroscopic basivertebral nerve laser ablation for chronic low back pain associated with modic changes: A preliminary open-label study. Pain Res Manag. 2018;2018:6857983.
12. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. International Society for the Advancement of Spine Surgery Guideline-intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain. Int J Spine Surg. 2020;14(1):18-25.
13. Michalik A, Conger A, Smuck M, Maus TP, McCormick ZL. Intraosseous basivertebral nerve radiofrequency ablation for the treatment of vertebral body endplate low back pain: Current evidence and future directions. Pain Med. 2021;22(Suppl 1):S24-S30. 15. Tieppo Francio V, Sherwood D, Twohey E, Barndt B, et al. Developments in minimally invasive surgical options for vertebral pain: Basivertebral nerve ablation - a narrative review. J Pain Res. 2021;14:1887-1907.
16. Conger A, Schuster NM, Cheng DS, Sperry BP, et al. The effectiveness of intraosseous basivertebral nerve radiofrequency neurotomy for the treatment of chronic low back pain in patients with modic changes: A systematic review. Pain Med. 2021;22(5):1039-1054.
17. Hayes, Inc. Hayes Evolving Evidence Review. Intracept intraosseous nerve ablation system (Relievant Medsystems Inc.) for treatment of adults with low back pain. Lansdale, PA: Hayes, Inc.; 09/28/2023
18. Nwosu M, Agyeman WY, Bisht A, et al. The effectiveness of intraosseous basivertebral nerve ablation in the treatment of nonradiating vertebrogenic pain: a systematic review. Cureus. 2023;15(4):e37114.
19. Conger A, Burnham TR, Clark T, Teramoto M, McCormick ZL. The effectiveness of intraosseous basivertebral nerve radiofrequency ablation for the treatment of vertebrogenic low back pain: an updated systematic review with single-arm meta-analysis. Pain Med. 2022;23(Suppl 2):S50-S62.
20. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back painrelated healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med. Published online August 29, 2023.
