Anthem Blue Cross Connecticut SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures Form

This document addresses several minimally invasive surgical procedures designed to destroy nociceptive nerve fibers with or without structural changes to the intervertebral discs. The following percutaneous vertebral disc and vertebral endplate procedures have been explored as a treatment of chronic low back pain secondary to disc disease:

• intradiscal electrothermal therapy (IDET) (also referred to as intradiscal electrothermal annuloplasty)
• percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
• intraosseous basivertebral nerve ablation
• intradiscal biacuplasty (IDB)

Note: Please see the following document for percutaneous and endoscopic spinal procedures designed to remove or ablate disc material and decompress the disc (for example, percutaneous lumbar discectomy, laser discectomy, and disc decompression using radiofrequency energy):

• SURG.00071 Percutaneous and Endoscopic Spinal Surgery

Position Statement

Medically Necessary:

Intraosseous basivertebral nerve ablation (BVNA) is considered medically necessary when all of the following criteria are met:

1. Individual is skeletally mature; and
2. Chronic unremitting low back pain of at least 6 months duration is present; and
3. Has failed to respond to at least 6 months of supervised conservative medical management (for example, exercise, nonsteroidal and/or steroidal medication [unless contraindicated], physical therapy, including passive and active treatment modalities, and activity/lifestyle modification); and
4. Diagnosis of vertebrogenic pain meeting the following criteria:
   1. Documented by history and physical examination; and
   2. Magnetic resonance imaging (MRI)-demonstrated Modic Type 1 or 2 changes in at least one vertebral endplate, at one or more levels from L3 to S1, including the following:
      1. Fibrovascular bone marrow changes are present (hypointense MRI signal for Modic Type 1); or
      2. Fatty bone marrow changes are present (hyperintense MRI signal for Modic Type 2);
         and
5. Qualifying Modic changes are exhibited at each level to be treated; and
6. Documentation that other causes of low back pain have been excluded (including, but not limited to: chronic lumbar strain, lumbar stenosis, degenerative scoliosis, facet arthropathy and disc disease).

Not Medically Necessary:

BVNA is considered not medically necessary when the criteria above are not met, and for all other indications.

Investigational and Not Medically Necessary:

The following procedures are considered investigational and not medically necessary:

1. Percutaneous intradiscal electrothermal therapy; or
2. Percutaneous intradiscal radiofrequency thermocoagulation; or
3. Intradiscal biacuplasty.