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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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that thermal destruction of the intraosseous basivertebral nerve (BVN) will be considered 
medically reasonable and necessary for the treatment of chronic lower back pain (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 magnetic resonance imaging (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. 
 
   
Limitations 
Services that are not reasonable and necessary cannot be covered by Medicare in the following: 
1. Skeletally immature patients (less than or equal to18 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 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. 
10. Radiographic evidence of any of the following that correlates with predominant physical complaints: 
- Lumbar/lumbosacral disc extrusion or protrusion greater than 5mm at levels L3-S1; 
- Lumbar/lumbosacral spondylolisthesis greater than 2mm at any level; 
- Lumbar/lumbosacral spondylolysis at levels L3-S1; 
- 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 information 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.