Coverage Criteria for Radiofrequency Ablation Policy

This document is a policy guide issued by Physician’s Health Plan of Northern Indiana regarding the coverage criteria for the Intracept™ Procedure, effective from September 15, 2025. It outlines the specific requirements that must be met for radiofrequency nerve ablation to be considered medically necessary. The criteria include the ablation of basivertebral nerves located between the L3 and S1 vertebrae, chronic low back pain lasting at least six months that has not responded to conservative care, and an MRI report that shows Type 1 and Type 2 Modic changes. Additionally, the document specifies contraindications that must be documented, such as severe cardiac or pulmonary issues, proximity of the ablation zone to sensitive structures, active infections, pregnancy, skeletal immaturity, and the presence of implanted electronic devices. Adherence to these criteria is crucial for ensuring that patients meet the medical necessity requirements.