Description of Procedure or Service

Electrothermal intradiscal annuloplasty therapies use radiofrequency energy sources to treat discogenic low back pain arising from annular tears. These annuloplasty techniques are designed to decrease pain arising from the annulus by thermocoagulating nerves in the disc and tightening of annular tissue.

Discogenic low back pain is a common, multifactorial pain syndrome that involves low back pain without radicular symptoms findings, in conjunction with radiologically confirmed degenerative disc disease. Typical treatment includes conservative therapy with physical therapy and medication management, with potential for surgical decompression in more severe cases.

A number of electrothermal intradiscal procedures have been introduced to treat discogenic low back pain; they rely on various probe designs to introduce radiofrequency (RF) energy into the disc. It has been proposed that heat-induced denaturation of collagen fibers in the annular lamellae may stabilize the disc and potentially seal annular fissures and that pain reduction may occur through the thermal coagulation of nociceptors in the outer annulus.

Some of the electrothermal intradiscal procedures are briefly described.

With the intradiscal electrothermal annuloplasty (IDEA) procedure, a navigable catheter with an embedded thermal resistive coil is inserted posterolaterally into the disc annulus or nucleus. Using indirect radiofrequency energy, electrothermal heat is generated within the thermal resistive coil at a temperature of 90 degrees centigrade; the disc material is heated for up to 20 minutes. Proposed advantages of indirect electrothermal delivery of radiofrequency energy with IDEA include precise temperature feedback and control, and the ability to provide electrothermocoagulation to a broader tissue segment than would be allowed with a direct radiofrequency needle. Annuloplasty using a laser-assisted spinal endoscopy kit to coagulate the disc granulation tissue (percutaneous endoscopic laser annuloplasty) has also been described.

Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) uses direct application of radiofrequency energy. With PIRFT, the radiofrequency probe is placed into the center of the disc, and the device is activated for only 90 seconds at a temperature of 70 degrees centigrade. The procedure is not designed to coagulate, burn, or ablate tissue. The Radionics RF Disc Catheter System has been specifically designed for this purpose.

Intradiscal biacuplasty involves the use of two cooled radiofrequency electrodes placed on the posterolateral sides of the intervertebral annulus fibrosus. It is believed that by cooling the probes a larger area may be treated than could occur with a regular needle probe. 

Vertebral body endplates have been proposed as a source of lower back pain, caused by intraosseous nerves. The basivertebral nerve (BVN) enters the posterior vertebral body and sends branches to the superior and inferior endplates. The BVN carries pain signals from damaged vertebral endplates, contributing to vertebrogenic low back pain. Vertebrogenic pain, transmitted via the BVN, has been purported to occur with endplate damage or degeneration.  Certain Modic changes seen on MRI indicate inflammatory endplate damage linked to vertebral body and/or disc degeneration. The Intracept® System is a minimally invasive procedure that uses radiofrequency ablation (RFA) to disrupt the BVN, preventing pain transmission between the endplates and the brain.

During the procedure, a fluoroscopically guided probe targets the BVN, ablating neurovascular tissue in the vertebral body to interrupt pain signals. By eliminating BVN function, this technique aims to reduce chronic low back pain for patients who show Modic changes but lack spinal instability or scoliosis. BVN ablation is considered an alternative to spinal fusion for those unresponsive to conventional treatments.

Regulatory Status

A variety of radiofrequency (RF) coagulation devices are cleared for marketing by the U.S. Food and Drug Administration (FDA), some of which are designed for disc nucleotomy. In 2002, the Oratec Nucleotomy Catheter (ORATEC Interventions, Menlo Park, CA, acquired by Smith & Nephew in 2002) was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The predicate device was the SpineCATH® Intradiscal Catheter, which received FDA clearance for marketing in 1999. Radionics (a division of Tyco Healthcare group) RF (Radiofrequency) Disc Catheter System received marketing clearance through FDA’s 510(k) process in 2000.

The Baylis Pain Management Cooled Probe received marketing clearance through the FDA’s 510(k) process in 2005. It is intended for use “in conjunction with the Radio Frequency Generator to create radiofrequency lesions in nervous tissue.”

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 for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care”. FDA reviewed the device and issued a substantially equivalent designation in August 2017 (K170827). In March of 2022, FDA issued a substantially equivalent designation for an additional Intracept Intraosseous Nerve Ablation System (Relievant Medsystems, Inc.; K213836). The prior device (K170827) is listed as the reference access instrument and the new indication adds a description of accompanying use case features, "...is also accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signals (Type 2 Modic change).”

Note: This policy does not address disc nucleoplasty, a technique based on the bipolar RF device (Coblation®; ArthroCare, Austin, TX, acquired by Smith and Nephew, 2014). With the coblation system, a bipolar radiofrequency device is used to provide lower energy treatment to the intervertebral disc, which is designed to provide tissue removal with minimal thermal damage to collateral tissue. Disc nucleoplasty is closer in concept to a laser discectomy, in that tissue is removed or ablated in an effort to provide decompression of a bulging disc. Disc nucleoplasty and laser discectomy are considered separately in the policy entitled, Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty). 

Related Policies:

Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)

Automated Percutaneous and Endoscopic Discectomy

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for Percutaneous Intraosseous Radiofrequency Procedures of the Spine when it is determined to be medically necessary and when the medical criteria and guidelines shown below are met. 

Percutaneous Intradiscal Procedures are considered investigational. BCBSNC does not provide coverage for investigational services or procedures.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine are covered

Intraosseous radiofrequency ablation of the basivertebral nerve using an FDA approved device for the treatment of vertebrogenic back pain may be considered medically necessary when all of the following criteria have been met:

• The individual is skeletally mature (≥ 18 years of age)
• The individual experiences moderate to severe chronic low back pain, which is primarily localized and axial in nature 
• MRI imaging demonstrates Modic Type I or II changes, endplate hypointensity (Type 1) or hyperintensity (Type 2) on T1 images plus hyperintensity on T2 images (Type 1) characterized by inflammation, edema, endplate disruption, and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, and/or replacement of bone marrow with fat in the vertebral endplates at each planned treatment levels between L3 and S1. Imaging reports are required to be submitted.  
• All other possible sources of pain including, but not limited to, fracture, disc herniation, spondylolisthesis, tumor, infection, or significant spinal deformity have been ruled out
• The individual has tried and failed six months of conservative, non-surgical treatment under the direction of a healthcare professional which must include physical therapy (physical therapy notes are required to be submitted), activity/lifestyle modification, epidural steroid or facet joint injections (if applicable), and pharmacotherapy
• No previous history of basivertebral nerve ablation has been performed at the planned level of treatment

Note: The Plan requires the submission of imaging reports and physical therapy notes, or access to them, to substantiate medical necessity. 

When Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine are not covered

Intraosseous radiofrequency ablation of the basivertebral nerve for the treatment of vertebrogenic back pain is considered investigational and not covered for any of the following scenarios:

• The above criteria are not met
• Evidence on imaging suggests another etiology for the individual’s back pain symptoms, including but not limited to lumbar stenosis, spondylolysis, segmental instability, disc herniation, spondylolistheses > 2mm, degenerative scoliosis or facet arthropathy or effusion with clinically suspected facet joint pain
• Primary symptoms include neurogenic claudication, lumbar radiculopathy or radicular pain due to neurocompression 
• Treatment with basivertebral nerve ablation at vertebral levels other than L3-S1 
• Repeat basivertebral nerve ablation at the same vertebral level

Intradiscal annuloplasty for the treatment of chronic discogenic back pain is considered investigational for all levels of the spine (i.e., cervical, thoracic, lumbar and sacral), whether performed percutaneously or using an open incision. This includes, but is not limited to, the following:

• Intradiscal electrothermal annuloplasty (IDEA) 
• Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) 
• Intradiscal biacuplasty

Policy Guidelines

For individuals with vertebrogenic back pain undergoing intraosseous ablation of basivertebral nerves, evidence primarily comes from two randomized controlled trials (RCTs): the SMART and INTRACEPT trials. Key outcomes include symptoms, functional improvements, quality of life (QOL), and treatment-related morbidity. The SMART trial found clinical improvements in the ODI and VAS scores were statistically significant compared with the baseline at all follow-up points in time through 2 years compared with patients treated with a sham procedure.  Of note, 73% of patients crossed over to the active treatment group at 12 months, limiting the availability of long-term comparative data. In contrast, the INTRACEPT trial reported a significant reduction in ODI and other pain scores at 3 months for patients treated with BVNA compared to standard care.

A 2024 study by Khalil et al. conducted a pooled analysis of three prospective clinical trials, showing sustained and clinically meaningful pain and function improvements lasting over five years. Also, of significance, they found no serious device-related events were reported, and researchers observed a reduction in opioid use and post-BVNA spinal injections. Similarly, Fischgrund et al. (2020) analyzed long-term outcomes in RCTs and follow-up studies over two, three, and five years. The study demonstrated improvements in pain, opioid use, activity levels, and quality of life, with 75% of patients reporting a significant pain reduction and less need for ongoing injections or opioid use. At the five-year follow-up, BVNA continued to show superior ODI and Visual Analog Scale (VAS) scores compared to baseline.

These findings suggest that BVNA may provide sustained pain relief for patients with Modic Type 1 or 2 changes who have not responded to conventional medical treatments such as physical therapy, injections, exercise, and pharmacotherapy. The International Society for the Advancement of Spine Surgery designated BVNA as Level 1 evidence, recommending it for carefully selected patients who are refractory to standard care. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have discogenic back pain who receive intradiscal electrothermal annuloplasty, the evidence includes a small number of randomized controlled trials (RCTs). Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Two RCTs on intradiscal electrothermal annuloplasty reported conflicting results, with one reporting benefit for intradiscal electrothermal annuloplasty and the other reporting no benefit. Further study in a sham-controlled trial with a representative population of patients is needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have discogenic back pain who receive intradiscal radiofrequency annuloplasty, the evidence includes two RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Neither RCT found evidence of benefit with the treatment. More sham-controlled trials are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have discogenic back pain who receive intradiscal biacuplasty, the evidence includes two industry-sponsored RCTs. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. One trial reported significant improvements at 6 months posttreatment, but not at 1 and 3 months. The other trial also showed a significant reduction in visual analog scale (VAS) scores at 6 months that appeared to continue to the 12-month follow-up; however, it is unclear whether this trial was sufficiently powered. More sham-controlled trials are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 22526, 22527, 22899, 64628, 64629 

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual, 7.01.72 – 5/31/01

Consultant review – 7/8/2001

Specialty Matched Consultant Advisory Panel – 8/2001

Specialty Matched Consultant Advisory Panel – 8/2002

BCBSA Medical Policy Reference Manual, 7.01.72, 7/12/02

Specialty Matched Consultant Advisory Panel – 7/2003

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 11/9/04

ECRI Target Report. #767. (2004, March). Intradiscal electrothermal therapy (IDET) for discogenic pain. Retrieved 1/26/05 from www.Target.ecri.org/summary/detail.aspx?doc_id=1154&q=IDET&anm=Wynne.

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 4/1/2005

Specialty Matched Consultant Advisory Panel – 6/2005

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 12/12/2006

Specialty Matched Consultant Advisory Panel – 5/2007

Freeman BJ and Mehdian R. Intradiscal electrothermal therapy, percutaneous discectomy, and nucleoplasty: what is the current evidence? Curr Pain Headache Rep 2008; 12(1):14-21.

National Institute for Clinical Excellence (NICE). Percutaneous intradiscal electrothermotherapy for low back pain. August 2004. Retrieved 3/9/09 from http://www.nice.org.uk/nicemedia/pdf/ip/IPG081guidance.pdf

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 4/24/09

Specialty Matched Consultant Advisory Panel – 5/2009

National Institute for Health and Clinical Excellence. (NICE) IPG319 Percutaneous intradiscal electrothermal therapy for low back pain: guidance. 2009; Last reviewed March 29, 2011 at: http://guidance.nice.org.uk/IPG319/Guidance/pdf/English.

National Institute for Health and Clinical Excellence. IPG83 Percutaneous intradiscal radiofrequency thermocoagulation for lower back pain. 2004; Last reviewed March 29,2011 at: http://guidance.nice.org.uk/IPG83.

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 8/12/10

Specialty Matched Consultant Advisory Panel – 5/2011

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 7/14/2011

Specialty Matched Consultant Advisory Panel – 5/2012

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 7/12/12

Specialty Matched Consultant Advisory Panel – 5/2013

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 7/11/2013

Senior Medical Director – 8/2013

Specialty Matched Consultant Advisory Panel – 5/2014

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 7/10/2014

Specialty Matched Consultant Advisory Panel – 5/2015

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 7/9/2015

Specialty Matched Consultant Advisory Panel – 5/2016

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 1/12/2017

Specialty Matched Consultant Advisory Panel – 5/2017

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 1/11/2018

Specialty Matched Consultant Advisory Panel – 5/2018

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 4/8/2019

Specialty Matched Consultant Advisory Panel – 5/2019

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 4/16/2020

Specialty Matched Consultant Advisory Panel – 5/2020

Fischgrund JS, Rhyne A, Macadaeg K, et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study [published online ahead of print, 2020 May 25]. Eur Spine J. 2020;10.1007/s00586-020-06448-x.

Fischgrund JS, Rhyne A, 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: 110-119

Khalil JG, 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; 19: 1620-1632.

Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study. Eur Spine J. 2018;27(5):1146-1156.

Medical Director review

BCBSA Medical Policy Reference Manual [Electronic Version]. 7.01.72, 4/8/2021

Specialty Matched Consultant Advisory Panel – 5/2021

Specialty Matched Consultant Advisory Panel – 5/2022

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.

Specialty Matched Consultant Advisory Panel – 5/2023

Medical Director review- 5/2024

Specialty Matched Consultant Advisory Panel – 5/2024

Khalil JG, Truumees E, Macadaeg K, Nguyen DTD, Moore GA, Lukes D, Fischgrund J. Intraosseous basivertebral nerve ablation: A 5-year pooled analysis from three prospective clinical trials. Interv Pain Med. 2024 Dec 13;3(4):100529. doi: 10.1016/j.inpm.2024.100529. PMID: 39758714; PMCID: PMC11700295

Smuck M, Khalil J, Barrette K, Hirsch JA, Kreiner S, Koreckij T, Garfin S, Mekhail N; INTRACEPT Trial Investigators. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. 2021 Aug;46(8):683-693. doi: 10.1136/rapm-2020-102259. Epub 2021 May 24. PMID: 34031220; PMCID: PMC8311085.

Markman JD, Rhyne AL, Sasso RC, Patel AA, Hsu WK, Fischgrund JS, Edidin AA, Vajkoczy P. Association Between Opioid Use and Patient-Reported Outcomes in a Randomized Trial Evaluating Basivertebral Nerve Ablation for the Relief of Chronic Low Back Pain. Neurosurgery. 2020 Mar 1;86(3):343-347. doi: 10.1093/neuros/nyz093.

Koreckij T, Kreiner S, Khalil JG, Smuck M, Markman J, Garfin S. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 24-month treatment arm results. NASSJ. Published online October 26, 2021. DOI: https://doi.org/10.1016/j.xnsj.2021.100089

Lorio M, Clerk-Lamalice O, Beall DP, Julien T. International Society for the Advancement of Spine Surgery Guideline-Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain. Int J Spine Surg. 2020 Feb 29;14(1):18-25. doi: 10.14444/7002. PMID: 32128298; PMCID: PMC7043835.

North American Spine Society.  (2025). Coverage recommendations for basivertebral nerve ablation.  Retrieved from https://www.spine.org

Medical Director review- 5/2025

Specialty Matched Consultant Advisory Panel – 5/2025

Policy Implementation/Update Information

Intradiscal Electrothermal (IDET) Annuloplasty

7/6/09 Herniated Lumbar Disc, Percutaneous policy separated into individual policies by topic. No change to policy statement. Description revised. Updated rationale in the "Policy Guidelines" section. References added. (btw)

1/5/10 Deleted HCPCS codes 0062T and 0063T from the "Coding/Billing" section. (btw)

6/22/10 Policy Number(s) removed (amw)

Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty

6/21/11 Combined Intradiscal Electrothermal annuloplasty and Percutaneous Intradiscal Radiofrequency annuloplasty. Renamed “Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty”. Specialty Matched Consultant Advisory Panel review 5/25/2011. Updated “Description” and “Policy” statements to reflect these services. No change to policy intent. “Intradiscal annuloplasty (e.g., intradiscal electrothermal annuloplasty, percutaneous intradiscal radiofrequency thermocoagulation, or intradiscal biacuplasty) for the treatment of chronic discogenic back pain is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures.” References added. (btw)

8/30/11 Reference added. (btw)

5/29/12 Specialty Matched Consultant Advisory Panel review 5/16/2012. Policy Guidelines updated. No change to policy statement. Removed deleted CPT code, 62288. (btw)

8/21/12 Removed deleted CPT codes 0062T and 0063T from Billing/Coding section (btw)

9/18/12 Reference added. (btw)

7/1/13 Specialty Matched Consultant Advisory Panel review 5/15/2013. Policy Guidelines updated. No change to policy intent. (btw)

9/10/13 Policy Guidelines section updated. Removed HCPCS code S2348 from Coding/Billing section as it does not pertain to this policy. Senior Medical Director review 8/29/2013. Reference added. (btw)

6/10/14 Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy. (btw)

11/11/14 Reference added. (sk)

7/1/15 Specialty Matched Consultant Advisory Panel review 5/26/2015. (sk)

9/1/15 Reference added. Codes 62292 and 64640 removed from Billing/Coding Section. (sk)

7/1/16 Specialty Matched Consultant Advisory Panel review 5/25/2016. (sk)

3/31/17 Reference added. Description section and Policy Guidelines Section revised. Title changed from Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty to Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty. Policy statement terminology revised to reflect the changes in the title but policy intent is unchanged. (sk)

6/30/17 Specialty Matched Consultant Advisory Panel review 5/31/2017. (sk)

3/9/18 Reference added. (sk)

6/29/18 Specialty Matched Consultant Advisory Panel review 5/23/2018. (sk)

12/14/18 Codes C9752 and C9753 added to Billing/Coding section for effective date 1/1/2019. (sk)

6/11/19 Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. (sk)

6/9/20 Reference added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. (bb)

7/14/20 References added. Regulatory Status updated. Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept® system) for the treatment of vertebrogenic back pain added to When Not Covered section. Policy Guidelines updated. Code 22899 added to Billing/Coding section. Title changed from Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty to “Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine”. Medical Director review. (sk)

6/15/21 Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021. (sk)

12/30/21 Added codes 64628 and 64629 to Billing/Coding section. (sk)

6/14/22 Policy Guidelines updated. Removed deleted codes C9752 and C9753 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/18/2022. (sk)

6/30/23 Policy Guidelines updated. Regulatory Status updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/17/2023. (sk)

5/29/24 References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. (ldh)

7/1/25 Description, Policy Guidelines, and Reference sections updated. Policy statement revised as follows: “BCBSNC will provide coverage for Percutaneous Intraosseous Radiofrequency Procedures of the Spine when it is determined to be medically necessary and when the medical criteria and guidelines shown below are met.” When Covered section revised with medically necessary criteria for intraosseous radiofrequency ablation of the basivertebral nerve. When Not Covered section revised to include when intraosseous radiofrequency ablation of the basivertebral nerve is investigational and not covered. Medical Director review 5/2025.  Specialty Matched Consultant Advisory Panel review 5/2025. (ldh)