Criteria
Basivertebral nerve ablation from L3 through S1 may be considered medically necessary when ALL of the following criteria have been met:
- 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 51% 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
