Intraosseous Radiofrequency Nerve Ablation of the Basivertebral Nerve for the Treatment of Low Back Pain

This policy covers intraosseous radiofrequency ablation of the basivertebral nerve (basivertebral nerve ablation, e.g., Intracept) for vertebrogenic axial low back pain targeting vertebral levels L3–S1 in skeletally mature patients. Coverage is limited to adults with chronic (≥6 months) axial low back pain as the primary symptom who have failed ≥6 months of conservative care and have MRI-confirmed Modic Type 1 or 2 endplate changes at L3–S1; it is not covered for patients without these findings, for those <18 years, or when other spinal pathology (e.g., radiculopathy, stenosis, fracture, infection, malignancy), severe cardiorespiratory compromise, BMI >40, or incompatible implantable electronic devices are present.

"Intraosseous radiofrequency ablation of the basivertebral nerve (procedure targeting L1–S1 vertebrae) for axial lower back pain of vertebrogenic origin."