Description
Thermal destruction or ablation of the of the intraosseous Basivertebral Nerve (BVN) is a therapeutic surgical procedure projected to treat chronic low back pain of a vertebrogenic origin only. The procedure uses fluoroscopic imaging to guide a thermal probe to the region of enervation in the vertebral body. Radiofrequency (RF) energy is applied to selectively destroy the BVN within the vertebral body. Medical documentation will be reviewed to determine if ablation of the Basivertebral Nerve (BVN) meets Medicare coverage criteria and documentation requirements.
Affected Code(s)
64628; 64629
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 4 – Part B Hospital, §20.4 – Reporting of Service Units
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39642: Intraosseous Basivertebral Nerve Ablation; Effective 01/28/2024; Revised 03/05/2026
10. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39644: Intraosseous Basivertebral Nerve Ablation; Effective 01/28/2024; Retired 03/05/2026
11. Palmetto GBA Local Coverage Determination (LCD) L39420: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain; Effective 03/05/2023
12. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A59466: Billing and Coding: Intraosseous Basivertebral Nerve Ablation; Effective 01/28/2024; Revised 03/05/2026
13. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A59468; Billing and Coding: Intraosseous Basivertebral Nerve Ablation; Effective 01/28/2024; Retired 03/05/2026
14. Palmetto GBA Local Coverage Article (LCA) A59205: Billing and Coding: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain; Effective 03/05/2023
15. Wellpoint Federal, Local Coverage Determination (LCD) L40302: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain; Effective 07/15/2026
16. Wellpoint Federal, Billing and Coding Article A60324: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain; Effective 07/15/2026
17. AMA CPT Codebook