Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty

This policy addresses percutaneous intradiscal electrothermal annuloplasty (IDET), intradiscal radiofrequency annuloplasty, and biacuplasty for treatment of discogenic low back pain—generally patients with chronic (>6 months) axial low back pain without radiculopathy, radiologic evidence of degenerative disc disease, failed conservative therapy, or positive provocation discography. Major limitations: these procedures are considered experimental/investigational and not routinely covered due to insufficient evidence of improved net health outcomes (although specific devices have 510(k) clearance), with coverage subject to the member’s benefit plan, state regulations, and limited use only under special governance/consent/audit or research arrangements.

"Discogenic low back pain: low back pain without radicular symptoms in conjunction with radiologically confirmed degenerative disc disease"