Coding
Clinical and Coding Components for Basivertebral Nerve Ablation: 2025 Update
Significant Developments in Coverage, Evidence, and Competitive Landscape
Hemant Kalia, MD, MPH
C.R.I.S.P. (Center for Research & Innovation in Spine & Pain) Rochester, NY
Peng Bai, DO
Carolina Spine Center Cary, NC
Jeffrey Stone, MD, FACR
Mayo Clinic Florida Jacksonville, FL
Donna Lahey, RNFA
Spine Institute of Arizona Scottsdale, AZ
Low back pain continues to be the leading cause of disability-adjusted life years globally, affecting over 619 million people in 2020 with projections reaching 843 million by 2050. Since an earlier SpineLine article on basivertebral nerve ablation (BVNA) in 2023, the landscape has changed substantially with expanded insurance coverage, robust long-term evidence, and the emergence of competitive technologies. This update provides clinicians with the latest information on medical necessity criteria, coverage differences among payers, and new treatment options entering the market.
Enhanced Clinical Evidence and Guidelines
More data on clinical effectiveness of five-year pooled outcomes data from three prospective clinical trials suggest sustained improvements in pain and function, with 76.4% of patients maintaining clinically meaningful improvements at 24 months. Notably, pooled 5-year results show that 32.1% of patients achieve 50-74% pain reduction, while 15.3% experience 75-99% reduction in pain scores.1
Health care utilization studies note significant reductions in downstream interventions, including a 70% reduction in active opioid use and 65% reduction in therapeutic lumbosacral spine injections five years post-procedure; 6.5% at five years, versus the 14% rate reported in similar populations at six months.
A cost-effectiveness analysis published in September 2024 reports that BVNA achieves an incremental cost-effectiveness ratio of $11,376 per quality-adjusted life year at a five-year time horizon, well below standard willingness-to-pay thresholds.2 This economic evidence supports the value proposition of BVNA in health care systems focused on cost-effective interventions.2
Medicare Coverage: Local Coverage Determination L396443
The establishment of Medicare Local Coverage Determination (LCD) L39644, effective January 28, 2024, represented a milestone for BVNA coverage[1]. The Noridian Healthcare Solutions LCD covers jurisdictions including Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.
Medicare Medical Necessity Criteria
Medicare considers BVNA medically reasonable and necessary when all of the following criteria are met:
Patient Selection
- Individual is skeletally mature with chronic low back pain (CLBP) for at least 6 months
- Lower back pain is the dominant symptom
- Type 1 or Type 2 Modic changes on MRI between L3 and S1
Conservative Management Requirements
Documented failure to improve despite nonsurgical management including at least three of the following modalities[1]:
- Avoidance of activities that aggravate pain
- Course of physical therapy or professionally directed therapeutic exercise program
- Chiropractic manipulation
- Cognitive therapy
- Pharmacotherapy (narcotic and non-narcotic analgesics, muscle relaxants, neuroleptics, anti-inflammatories)
- Injection therapy of epidural or facet joint implicated pain sources
Clinical Assessment
- Physical and psychological assessment of patient's ability to tolerate and benefit from BVN ablation
- Absence of additional vertebral pathology that could cause symptoms or complicate the procedure
Medicare Limitations and Contraindications
Treatment Limitations
- No previous history of BVN ablation at the planned level
- Maximum of 1-2 vertebral bodies per session
- Treatment of no more than 4 vertebral bodies per patient lifetime
- Treatment confined to L3-S1 vertebral bodies
- Retreatment of a single vertebral body is not covered
Contraindications
- Skeletal immaturity (<18 years)
- Evidence of other etiology for LBP (stenosis, spondylolisthesis, disc herniation, etc.)
- Metabolic bone disease (osteoporosis with T-score <-2.5)
- Active spine or systemic infection
- Neurogenic claudication or radiculopathy as primary symptoms
- Implantable pulse generators without specific precautions
- Ongoing substance abuse without evidence of potential weaning
Commercial Payer Coverage Variations
While Medicare's LCD provides a foundation, commercial payers vary significantly in their coverage criteria. Analysis of major commercial policies reveals both similarities and key differences. Commercial payer differences include:
BMI Restrictions
- Several commercial payers exclude patients with BMI >40
- Medicare LCD does not specify BMI restrictions
- Some plans allow BMI >40 if weight is not the main contributing factor
Additional Clinical Requirements
- Some payers require minimum Oswestry Disability Index (ODI) scores >30
- Minimum numerical rating scale scores ≥4
- Specific diagnostic injection requirements if concurrent pathology present
Prior Authorization
- Most commercial plans require prior authorization
- Medicare does not require prior authorization but mandates LCD compliance documentation
Updated Coding and Billing Considerations
The CPT coding structure for BVNA remains unchanged from the 2023 SpineLine article, but several important updates warrant attention, including:
Current CPT Codes
- Most commercial plans require prior authorization
- Medicare does not require prior authorization but mandates LCD compliance documentation
Medicare Medically Unlikely Edit (MUE)
CMS has implemented a Medically Unlikely Edit on CPT code 64629, meaning that billing for a fourth vertebral body is likely to be denied. This aligns with the LCD limitation of treating no more than 4 vertebral bodies per patient lifetime, with a maximum of 1-2 vertebral bodies per session.
Documentation Requirements
Enhanced documentation requirements reflect the maturation of coverage policies:
Required Documentation:
- Complete history and physical examination
- Pain and disability measurement scales (NRS, VAS, ODI, PROMIS)
- MRI documentation confirming Modic changes (Type 1 or 2) in L3-S1 endplates
- Comprehensive treatment history including dates and outcomes of conservative measures
- Provider qualifications and facility credentials
Anesthesia Considerations
Medicare LCD specifies that local anesthesia is considered appropriate, with mild sedation permissible under physician direction. Higher levels of sedation or general anesthesia require documentation of medical necessity and should be provided by qualified separate providers.
Quality Measures and Outcomes Documentation
Given the robust evidence base, providers should consider implementing standardized outcome measures:
Recommended Assessment Tools:
- Oswestry Disability Index (ODI)
- Numerical Rating Scale (NRS) or Visual Analog Scale (VAS)
- PROMIS domains for comprehensive functional assessment
- Patient Global Impression of Change (PGIC)
- Health care utilization tracking
Pre- and postprocedure documentation of these measures supports both quality improvement initiatives and potential coverage appeals when necessary.
Practice Implementation Considerations
Training and Credentialing
Medicare LCD emphasizes that providers must be appropriately trained through formal residency/fellowship programs or postgraduate courses accredited by established national credentialing bodies. Core curriculum should include:
- Anatomy and pharmacodynamics understanding
- Proficiency in evaluation, diagnosis, and management
- Technical procedure performance
- Imaging interpretation and performance
- Complication evaluation and management
Facility Requirements
Procedures must be performed in settings with:
- Appropriate equipment (fluoroscopy, CT, emergency equipment)
- Qualified clinical staff trained as first responders
- Immediate availability of support services equivalent to hospital standards
Future Outlook and Emerging Trends
Several trends are shaping the future of BVNA:
Technology Innovation: The introduction of competitive systems is driving innovation in procedure efficiency, targeting accuracy, and safety features. There are other competitive systems which will be coming out soon in BVNA space. The BVNA market has evolved from a single-product landscape to one with multiple competitive options, enhancing physician choice and potentially driving innovation
Coverage Expansion: The establishment of Medicare LCD creates a foundation for additional commercial payer coverage. Medicare Advantage plans must follow the least restrictive coverage policy between their own criteria and local Medicare LCD requirements.
Clinical Evidence Evolution: Ongoing studies are exploring BVNA in combination with other interventions, predictive factors for success, and expansion to additional spinal levels.
Conclusion
Basivertebral nerve ablation has evolved from an emerging therapy to a reimbursable treatment option for vertebrogenic chronic low back pain. The establishment of Medicare coverage through LCD L39644, expansion of commercial payer coverage, and emergence of competitive technologies mark significant milestones in the field's maturation.
Clinicians should be aware of the specific coverage criteria variations among payers, with particular attention to age restrictions, BMI limitations, and conservative care requirements that may differ from Medicare standards.
As the field continues to evolve, ongoing attention to appropriate patient selection, comprehensive documentation, and outcomes measurement will be essential for maintaining coverage and optimizing patient care. The robust evidence base supporting BVNA, combined with its cost-effectiveness profile, positions this therapy as a valuable tool in the comprehensive management of chronic low back pain.
References
- Khalil JG, Truumees E, Macadaeg K, Nguyen DT, Moore GA, Lukes D, Fischgrund J. Intraosseous basivertebral nerve ablation: A 5-year pooled analysis from three prospective clinical trials. Interverv Pain Med. 2024. 3(4), 100529.
- Smuck M, McCormick ZL, Gilligan C, Hailey MK, Quinn ML, Bentley A, Taylor RS. (2025). A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J. 2025. 25(2), 201-210.
- Centers for Medicare & Medicaid Services. Intraosseous Basivertebral Nerve Ablation. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39644
Author Disclosures
H Kalia: Board of Directors: Monroe County Medical Society (Nonfinancial); Consulting: Abbott (C), Curonix (B); Other: North American Neuromodulation Society (Nonfinancial, chair education committee member); Scientific Advisory Board: Nalu (B); Speaking and/or Teaching Arrangements: Averitas (B).
P Bai: Nothing to disclose
J Stone: Other: North American Spine Society (Coding Committee, Radiology Committee); Research Support (Staff and/or materials): Benvenue Medical (Nonfinancial, Outside 24-Month Requirement); Speaking and/or Teaching Arrangements: North American Spine Society (Honorarium for Spine Coding Course).
D Lahey: Speaking and/or Teaching Arrangements: NASS (A, Paid directly to institution/employer); Trips/Travel: NASS (Travel Expense Reimbursement, Paid directly to institution/employer).