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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 say that low back pain (LBP) is the most expensive occupational disorder in the United States and the 
leading cause of disability worldwide. Chronic low back pain (cLBP) is defined as persistent pain in the lumbar 
region lasting for >12 weeks. cLBP has many different etiologies. Research shows evidence that one etiology is 
associated with degeneration of the vertebral body or vertebral body endplates, resulting in inflammation. The 
inflammatory response is perceived by the basivertebral nerve (BVN), a sensory nerve that enters the posterior 
vertebral body and branches out to the superior and inferior endplates. The pain signals are then transmitted to 
the central nervous system, causing what is known as vertebrogenic pain. 
 
Clinically, vertebrogenic pain is generally described as a midline, deep, aching, burning pain that is 
progressive. Also, it is often associated with an intermittent electrical shock sensation. Vertebrogenic pain is 
also characterized by absence of radicular expression, lower extremity weakness, or sensory deficits, and the 
neural tension sign and pain is generally worse with spinal flexion, sitting, standing and general physical 
activity, when compared to extension. 
 
Diagnosis of vertebrogenic cLBP focuses on the chronic inflammatory response caused by endplate damage, 
which is visible on magnetic resonance imaging. These signal changes, known as Modic changes (MC), are 
found in the vertebral body bone marrow that is adjacent to the degenerative endplates. Modic 1 changes 
indicate inflammation and edema, and Modic 2 changes occur in the setting of marrow ischemia when the red 
hematopoietic bone marrow has converted into yellow fatty marrow. 
 
Thermal destruction (i.e., ablation) of the intraosseous BVN (Intracept  Procedure) is a therapeutic, 
interventional surgical procedure used to treat cLBP of vertebrogenic origin. The procedure is performed using 
fluoroscopic imaging under moderate/conscious sedation or general anesthesia. Radiofrequency energy is 
applied for 15 minutes at 85 degrees Celsius to produce a lesion to destroy the BVN within the vertebral body. 
At a minimum, the BVN is ablated in at least 1 vertebral body. 
 
Covered Indications 
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: Chronic lumbar back pain of =6 months duration that causes functional deficit measured on a pain or disability 
scale*, AND 
Documented failure to respond to =6 months of non-surgical management**, AND 
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 
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. 
 
You can find these rules in the Local Coverage Determination (LCD) 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.