Intraosseous Basivertebral Nerve Ablation
L39642
Basivertebral nerve (BVN) ablation is covered for skeletally mature patients with chronic low back pain (≥6 months) as the dominant symptom who have failed at least three documented conservative treatments and have MRI-confirmed Type 1 or Type 2 Modic changes at L3–S1, with no other vertebral pathology. Treatment is limited to L3–S1 levels, up to 1–2 levels per session and a maximum of four vertebral bodies lifetime; multiple listed medical conditions (eg, active infection, metabolic bone disease, radiculopathy, implantable pulse generators without precautions) and other contraindications render the procedure not medically necessary. Required documentation includes duration and dominance of symptoms, failed conservative therapies, MRI confirming Modic changes, imaging/clinical exclusion of other pathologies, physical/psychological assessment, and procedural level/prior-treatment records.
"Patient is skeletally mature."