Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules state that thermal destruction of the intraosseous BVN will be considered medically reasonable and 
necessary for the treatment of cLBP in patients who meet ALL the following criteria: 
1. Chronic lumbar back pain of greater than or equal to 6 months duration that causes functional deficit 
measured on a pain or disability scale, AND 
2. Documented failure to respond to greater than or equal to 6 months of non-surgical management, AND 
3. Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain 
the source of the patients pain, including but not limited to fracture, tumor, infection, or significant 
deformity, AND 
4. Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate 
changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent 
marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow 
including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), 
in 1 or more vertebrae from L3-S1. 
Pain assessment and a disability scale must be obtained at baseline to be used for functional assessment. 
Non-surgical management may include but is not limited to: 
 Avoidance of activities that aggravate pain; 
 Trial of Chiropractic manipulation; 
 Trial of Physical Therapy; 
 Cognitive support and recovery reassurance; 
 Injection therapy  epidural and/or facet; 
 Spine biomechanics education; 
 Specific lumbar exercise program; 
 Home use of heat/cold modalities; 
 Low impact aerobic exercise as tolerated;  Pharmacotherapy (e.g., non-narcotic analgesics, NSAIDs, muscle relaxants, neuroleptics, and 
narcotics). 
Patients must have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to 
thermal destruction of the intraosseous BVN (such screening must include psychological, as well as, physical 
evaluation). Documentation of the history and careful screening must be available in the patient chart if 
requested. 
Limitations 
Services that are not reasonable and necessary cannot be covered by Medicare in the following:
1,2,5,9,10,11,12,13
 
1. Skeletally immature patients (less than or equal to 18 years old); 
2. Severe cardiac or pulmonary compromise; 
3. Active systemic infection or local infection at the intended treatment level; 
4. Bleeding diathesis; 
5. Pregnancy; 
6. Primary radicular pain into the lower extremities (defined as nerve pain following a dermatomal 
distribution and that correlates with nerve compression on imaging); 
7. Previous lumbar/lumbosacral spine surgery at the intended treatment level (with the exception of 
discectomy/laminectomy if performed greater than 6 months prior to BVN nerve ablation and radicular 
pain resolved); 
8. Primary symptomatic lumbar or lumbosacral spinal stenosis (defined as the presence of neurogenic 
claudication and confirmed by imaging); 
9. Diagnosed osteoporosis (T-score of -2.5 or less), spine fragility fracture history, trauma/compression 
fracture at the intended treatment level, or spinal cancer; 
10. Radiographic evidence of any of the following that correlates with predominant physical complaints:  
a. Lumbar/lumbosacral disc extrusion or protrusion greater than 5mm at levels L3-S1; 
b. Lumbar/lumbosacral spondylolisthesis greater than or equal to 2mm at any level; 
c. Lumbar/lumbosacral spondylolysis at levels L3-S1; 
d. Lumbar/lumbosacral facet arthrosis/effusion correlated with facet-mediated pain at levels L3-
S1. 
11. BMI greater than 40; 
12. Advanced generalized systemic disease that limits quality-of-life (QOL) improvements would require a 
statement of the objective of treatment in such cases; 
13. Active, untreated substance abuse disorder. 
You can find this rule in the Local Coverage Determination (LCD) for Thermal Destruction of the Intraosseous 
Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain, L39420. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.