INTRAOSSEOUS RADIOFREQUENCY ABLATION OF THE BASIVERTEBRAL NERVE FOR CHRONIC LOW BACK PAIN (REQUIRES PREAUTHORIZATION)

III.237





III.237 INTRAOSSEOUS RADIOFREQUENCY ABLATION OF THE BASIVERTEBRAL NERVE FOR CHRONIC LOW BACK PAIN (REQUIRES PREAUTHORIZATION)


Description

Intraosseous radiofrequency ablation of the basivertebral nerve is a minimally invasive, outpatient procedure for patients with vertebrogenic pain. The Intracept® Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency (RF) generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae.

Vertebrogenic pain is caused when the vertebral endplates degenerate and cause pain due to the damage to intraosseous nerves.  The intraosseous nerve (basivertebral) weaves through the vertebral bodies.  This can result in chronic low back pain.

The diagnosis of vertebral endplate pain is made using a classification scale known as Modic changes (Type 1 or Type ).  Modic changes are areas of bone marrow damage that appear on Magnetic Resonance Imaging (MRI). 

Intracept® and OptaBlate BVN are the only procedure specifically approved for the treatment of basivertebral nerve pain. 



Dates

  • Original Effective
    03-16-2021
  • Last Review
    05-07-2025
  • Next Review
    05-05-2026

Policy

I.  Intraosseous radiofrequency ablation of the basivertebral nerve (L3 through S1 vertebrae) is scientifically validated when all of the following are met:

     A.  Skeletally mature patients (age >18 years old), AND

     B.  Chronic low back pain for at least 6 months, AND

     C.   Conservative measures tried and failed:

                   1.  At least 6 weeks of documented physical therapy AND

                   2.  At least 6 months of pharmacotherapy (narcotics, non-narcotic analgesics, muscle relaxants, neuroleptics, and/or anti-inflammatories) AND

     D.  MRI demonstrates Type 1 or Type 2 Modic changes at one or more vertebrae from L3 to S1, AND

     E.   Activities of daily living limited due to persistent low back pain

II.  All other uses of intraosseous radiofrequency ablation are considered investigational.



Guidelines

There are 2 types of Modic changes found on Magnetic Resonance Imaging (MRI):

  • Type 1 – Vascular development in the vertebral body, inflammation and edema, vertebral endplate changes, vascularized fibrous tissues within the adjacent marrow, hypointensive signals.

  • Type 2 – Changes in the vertebral body’s bone marrow including replacement of normal bone marrow by fat, and hyperintensive signals.

Contraindications for intraosseous radiofrequency ablation of the basivertebral nerve:

  • Skeletally immature patients (< 18  years old)
  • Severe cardiac or pulmonary compromise
  • Radicular pain
  • Targeted ablation zone is <10mm away from sensitive structure not intended to be ablated, including the vertebral foramen
  • Active systemic infection or local infection in the area to be treated
  • Patients who are pregnant
  • Skeletally immature patients (<18 years)
  • Patients with implantable pulse generators (pacemakers, defibrillators) or other electron implants


Quick Code Search

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Procedure

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Diagnosis

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Codes

      
          Full Description
            UNLISTED PROCEDURE, SPINE
      
          Full Description
            Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral
      
          Full Description
            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)




References

2019

Khalil J, Smuck M, Koreckij T, et al. A prospective randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. The Spine Journal. 2019; Oct;19(10)L1620-1632.
2019

Fischgrund J, 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. International Journal of Spine Surgery.2019;13(2):110-119.
2020

Lorio M, Clerk-Lamalice O, Beall D, Julien J. International Society for the Advancement of Spine Surgery Guideline-Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain. Internation Journal of Spine Surgery. 2020;14(1):18-25. 
2020

Macadaeg K, Truumees E, Boody B et al. A prospective, single arm study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain:12-month results. (2020). North American Spine Society Journal. 3. https://doi.org/10.1016/j.xnsj.2020.100030
2019

Truumees E, Macadaeg K, et al. A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. 2019;28:1594-1602.
2021

Smuck M, Khalil J, Barrette K, et al. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. Aug 2021; 46(8): 683-693. PMID 34031220
2022

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. PMID 36266051
2021

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. PMID 35141653

Revisions

01-21-2026

Updated the description to include both Intracept and OptaBlate BVN.
03-05-2025

References updated with no changes to policy. Removed codes C9752 & C9753 - codes termed 12/31/2021.
05-02-2024

Policy reviewed at Medical Policy Committee meeting on 05/01/2024 – no changes to policy.
01-31-2024

Adde clarifying verbiage around conservative measures.  
12-27-2023

Included L3 through S1 vertebrae in policy for clarification. 
01-06-2022

Added codes 64628 and 64629