Basivertebral Nerve Ablation

Policy ID: Z-104-005

Section: Miscellaneous

Effective Date: January 03, 2022

Revised Date: September 25, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Basivertebral nerve ablation is a minimally invasive radiofrequency ablative procedure that is intended to ablate or destroy the basivertebral nerve in the vertebral body to reduce chronic low back pain.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Basivertebral nerve ablation from L3 through S1 may be considered medically necessary when ALL of the following criteria have been met:

- The individual is skeletally mature; and
- The individual has chronic low back pain of at least six (6) months duration; and
- The individual has failed to respond to at least six (6) months of conservative treatment; and
- The individual's MRI demonstrates Modic change one (1) (MC1) or Modic change two (2) (MC2) in at least one (1) vertebral endplate at one (1) or more levels from L3 through S1.

The individual must receive at least 51percent or greater benefit from the basivertebral nerve ablation prior to repeat procedure.

More than two (2) basivertebral nerve ablations per benefit year will be 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.

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.

Procedure Codes

64628

64629

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 64628, and 64629.

M47.816

M47.817

M51.360

M51.361

M51.362

M51.369

M51.370

M51.371

M51.372

M51.379

M54.50

M54.51

M54.59

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

New policy for North Dakota with coding updates

Added: 64628, 64629
Removed: Procedure Code 22899
Removed: Outpatient HCPCS (C codes) C9752 and C9753

Internal Medical Policy Committee 01-20-22 Coding update - Effective January 01, 2022

Added Diagnosis code: 54.59

Internal Medical Policy Committee 9-12-2023 Annual Review -no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Updated references; and
Added bullet: The individual is skeletally mature

Internal Medical Policy Committee 9-17-2024 Coding update - Effective October 01, 2024

Removed diagnosis codes M51.36 and M51.37; and
Added diagnosis codes M51.360; M51.361; M51.362; M51.369; M51.370; M51.371; M51.372; M51.379; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Z-104-004

Section: Miscellaneous

Effective Date: January 03, 2022

Revised Date: March 12, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Archived Date: September 30, 2024

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted for this policy will be processed accordingly to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Basivertebral nerve ablation from L3 through S1 may be considered medically necessary when ALL of the following criteria have been met:

- The individual is skeletally mature; and
- The individual has chronic low back pain of at least six (6) months duration; and
- The individual has failed to respond to at least six (6) months of conservative treatment; and
- The individual's MRI demonstrates Modic change one (1) (MC1) or Modic change two (2) (MC2) in at least one (1) vertebral endplate at one (1) or more levels from L3 through S1.

The individual must receive at least 51percent or greater benefit from the basivertebral nerve ablation prior to repeat procedure.

Procedure Codes

64628

64629

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 64628, and 64629.

M47.816

M47.817

M51.36

M51.37

M54.50

M54.59

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 01, 2022

New policy for North Dakota with coding updates

Added: 64628, 64629
Removed: Procedure Code 22899
Removed: Outpatient HCPCS (C codes) C9752 and C9753

Internal Medical Policy Committee 01-20-22 Coding update - Effective January 01, 2022

Added Diagnosis code: 54.59

Internal Medical Policy Committee 9-12-2023 Annual Review -no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Updated references
Added bullet: The individual is skeletally mature; and

Internal Medical Policy Committee 3-19-2024 Coding update - Effective May 06, 2024

Added diagnosis code M54.51; and
Added Policy Application

Medical Policies Quick Search

Basivertebral Nerve Ablation

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 64628, and 64629.

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 64628, and 64629.

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer