Medical Policy Content

Policy ID: Z-104-006

Section: Miscellaneous

Effective Date: January 01, 2026

Applies To: Commercial, Medicaid Expansion, and Metallic

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 51 percent 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

American Society of Pain and Neuroscience

In 2022, the American Society of Pain and Neuroscience (ASPN) released guidelines on interventional treatments for low back pain. Regarding basivertebral nerve ablation, the Society recommends basivertebral nerve ablation (Grade A with Level of Certainty 1a) for patients with axial lower back pain of vertebrogenic nature.

International Society for the Advancement of Spine Surgery

In 2022, the International Society for the Advancement of Spine Surgery published updated guidelines on intraosseous basivertebral nerve ablation. The guideline was informed by a systematic review which included 2 randomized controlled trials (RCTs) and additional single-arm studies. The guideline authors concluded that intraosseous ablation of the basivertebral nerve from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain when all the following criteria are met:

Chronic low back pain of at least 6 months duration.
Failure to respond to at least 6 months of nonsurgical management.
Magnetic resonance imaging-demonstrated MC1 or MC2 in at least 1 vertebral endplate at 1 or more levels from L3 to S1. (*Endplate changes, inflammation, edema, disruption, and/or fissuring.)
Fibrovascular bone marrow changes (hypointense signal for Modic type 1).
Fatty bone marrow changes (hyperintense signal for Modic type 2).

CURRENT CODING

CPT

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Commercial

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Commercial

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Metallic

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Metallic

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Medicaid Expansion

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Medicaid Expansion

References

1. Fischgrund JS, Rhyne A, Macadaeg K, 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, 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.

3. Khalil JG, Smuck M, Koreckij T, 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.

4. Smuck M, Khalil J, Barrette K, et al; INTRACEPT trial investigators. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. 2021;46(8):683-693.

5. Markman JD, Rhyne AL, Sasso RC, 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. Neurosurgery. 2020;86(3):343-347.

6. Truumees E, Macadaeg K, Pena E, et al. A prospective, open-label, 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.

7. Urits I, Noor N, Johal AS, et al. Basivertebral nerve ablation for the treatment of vertebrogenic pain. Pain Ther. 2021;10(1):39-53.

8. Tieppo Francio V, Sayed D. Basivertebral nerve ablation. 2021. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.

9. De Vivo AE, D'Agostino G, D'Anna G, et al. Intra-osseous basivertebral nerve radiofrequencyablation (BVA) for the treatment of vertebrogenic chronic low back pain. Neuroradiology.2021;63(5):809-815.

10. 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.

11. Tieppo Francio V, Sherwood D, Twohey E, et al. Developments in minimally invasive surgical options for vertebral pain: Basivertebral nerve ablation - a narrative review. J Pain Res.2021;14:1887-1907.

12. Conger A, Schuster NM, Cheng DS, 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

13. 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.

14. 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.

15. 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.

16. McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med. 2024;25(1):20-32.

17. Koreckij T, Kreiner S, Khalil JG, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 24-Month treatment arm results. N Am Spine Soc J. Dec 2021; 8: 100089.

18. U.S. Food & Drug Administration. K213836 Intracept Intraosseous Nerve Ablation System 510k Summary. 2022. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K213836.

19. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022; 15: 3729-3832.

20. Lorio M, Clerk-Lamalice O, Rivera M, et al. ISASS Policy Statement 2022: Literature Review of Intraosseous Basivertebral Nerve Ablation. Int J Spine Surg. Dec 2022; 16(6): 1084-1094.

21. Fischgrund JS, Rhyne A, Macadaeg K, 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. Aug 2020; 29(8): 1925-1934

ND Committee Review

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

Adopted policy for North Dakota with coding updates
- Added: 64628; 64629; and
- Removed: Procedure Code 22899; and
- 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

Internal Medical Policy Committee 9-4-2025 Annual Review -no changes in criteria-Effective November 03, 2025

Internal Medical Policy Committee 11-6-2025 Revision-Effective January 01, 2026

Updated References; and
Added Professional Statement

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-104-005

Section: Miscellaneous

Effective Date: November 03, 2025

Applies To: Commercial, Medicaid Expansion, and Metallic

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 51 percent 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

M51.360

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

CURRENT CODING

CPT

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Commercial

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Commercial

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Metallic

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Metallic

64628

Heat destruction of intraosseous basivertebral nerve in bones of spine in lower back, first two bones

Medicaid Expansion

64629

Heat destruction of intraosseous basivertebral nerve in additional bone of spine in lower back

Medicaid Expansion

References

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.
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.
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.
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.
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: 12- month results. Reg Anesth Pain Med. 2021;46(8):683-693.
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.
Truumees E, Macadaeg K, Pena E, Arbuckle J 2nd, et al. A prospective, open- label, 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.
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.
Tieppo Francio V, Sayed D. Basivertebral nerve ablation. 2021. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.
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.
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.
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.
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.
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.
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.
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
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.
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.
McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain- related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. Pain Med. Published online August 29, 2023.

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

Internal Medical Policy Committee 9-04-2025 Annual Review -no changes in criteria- Effective November 03, 2025

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policy Search

Medical Policy Content