Is the Intracept Procedure (intraosseous ablation of the basivertebral nerve (BVN)) medically necessary for a patient with a diagnosis of vertebrogenic low back pain (M54.51)?

Medical Necessity Assessment for Basivertebral Nerve Ablation (Intracept Procedure)

The Intracept procedure (intraosseous ablation of the basivertebral nerve) is medically necessary for patients with vertebrogenic low back pain (M54.51) who meet specific clinical criteria, based on strong recommendations from the most recent high-quality guidelines. 1

Guideline Support for BVN Ablation

The 2025 BMJ clinical practice guideline—the most recent and highest quality evidence available—provides a strong recommendation FOR basivertebral nerve ablation for chronic back pain, representing a significant departure from recommendations against most other interventional spine procedures. 1 This is further supported by the American Society of Pain and Neuroscience (ASPN), which issued a strong recommendation with Level A grade evidence (high certainty that the net benefit is substantial) for BVN ablation in appropriately selected patients. 1, 2

Critical Context: BVN Ablation vs. Other Interventional Procedures

The 2025 BMJ guideline issued strong recommendations AGAINST most common interventional procedures for chronic spine pain, including: 3

• Joint radiofrequency ablation (facet RFA)
• Epidural steroid injections
• Facet joint injections
• Intramuscular trigger point injections

BVN ablation stands alone as having a strong FOR recommendation in this guideline, making it uniquely supported among interventional spine procedures. 1

Required Clinical Criteria for Medical Necessity

For BVN ablation to be medically necessary, patients must meet ALL of the following criteria:

1. Duration and Severity Requirements

• Chronic low back pain present for ≥6 months despite conservative treatment 4, 5, 2
• Pain severity sufficient to limit activities of daily living 5
• Axial (midline) low back pain, not radicular pain 6, 7

2. Imaging Requirements

• MRI demonstrating Modic Type 1 or Type 2 endplate changes at levels L3-S1 5, 2
• These signal changes on MRI represent vertebral endplate inflammation/degeneration and are essential diagnostic criteria 6, 7

3. Clinical Pain Pattern

• Pain worse with forward flexion (sitting, bending) 6
• Axial low back pain without significant leg pain 7
• Pain localized to the anterior column (vertebral bodies/endplates) rather than posterior elements 6

4. Conservative Treatment Failure

• Minimum 6 months of failed conservative management including: 4, 5
  • Physical therapy
  • NSAIDs and/or other analgesics
  • Activity modification
  • Other appropriate non-surgical interventions

5. Exclusion Criteria

• No active infection or malignancy 4
• No significant disc herniation causing radicular symptoms 7
• No prior fusion at the intended treatment levels 4

Key Distinction: No Diagnostic Blocks Required

Unlike facet radiofrequency ablation, BVN ablation does NOT require prior diagnostic nerve blocks. 6, 4, 2 The diagnosis of vertebrogenic pain is established through:

• Clinical presentation (axial pain worse with flexion)
• MRI findings (Modic changes)
• Exclusion of other pain generators

This represents a fundamental difference from facet-mediated pain, where confirmatory diagnostic blocks with ≥80% pain relief are required before ablation. 8, 9

Evidence Quality and Clinical Outcomes

The randomized controlled trial supporting BVN ablation demonstrated: 5

• Mean ODI improvement of -25.3 points in treatment arm vs. -4.4 in standard care (p<0.001)
• 74.5% of patients achieved ≥10-point ODI improvement vs. 32.7% in standard care
• Mean VAS pain reduction of -3.46 cm vs. -1.02 cm in standard care (p<0.001)
• Benefits maintained at 2-year follow-up

The study was halted early due to clear statistical superiority, with the data management committee recommending early crossover for control patients. 5

Common Pitfalls to Avoid

1. Do not confuse vertebrogenic pain with facet-mediated pain: Vertebrogenic pain is anterior column pathology with Modic changes; facet pain is posterior element pathology requiring diagnostic blocks. 6, 7

2. Do not require diagnostic blocks: This is not a diagnostic block-dependent procedure like facet RFA. 4, 2

3. Do not approve without Modic changes on MRI: The presence of Modic Type 1 or 2 changes is an absolute requirement for diagnosis. 5, 2

4. Do not approve for radicular pain: This procedure is specifically for axial vertebrogenic pain, not leg pain or radiculopathy. 6, 7

Recommendation for This Case

Medical necessity is established IF the patient meets all clinical criteria outlined above, particularly:

• ≥6 months chronic axial low back pain
• MRI-documented Modic Type 1 or 2 changes at L3-S1
• Failed conservative treatment for ≥6 months
• Pain pattern consistent with vertebrogenic etiology (worse with flexion)
• No significant radicular component

The procedure should be approved without requiring diagnostic blocks, as the diagnosis is established through clinical and imaging criteria. 1, 2 The 2025 BMJ guideline's strong recommendation FOR this procedure, in contrast to recommendations AGAINST most other spine interventions, provides the highest level of guideline support available. 3, 1