Coverage Criteria for Thermal Ablation of BVN

This document is a medical policy guide detailing the coverage criteria for the thermal ablation of the intraosseous basivertebral nerve (BVN) under Medical Mutual's commercial plans. Effective February 1, 2026, the policy outlines the clinical indications necessary for medical necessity, as well as the non-indications that would render the procedure inappropriate. The criteria specify that patients must be skeletally mature and have chronic lumbar back pain lasting six months or more, among other requirements. The document also lists specific imaging and evaluation criteria that must be met, including the necessity of MRI documentation of Modic changes in the relevant vertebrae. Additionally, it details frequency limitations for the procedure and enumerates various medical conditions that would disqualify a patient from receiving the treatment. The guide emphasizes the importance of thorough documentation in patient charts to ensure compliance with these criteria.