Cigna Healthcare (Commercial) · basivertebral nerve ablation

v1verified 2026-07-24manual-pull source

✗ investigational / not covered · commercial

Criteria checklist

0 of 5 ticked

Indications

enumerated: yes
covered:
investigational:
- radiofrequency ablation of the intraosseous basivertebral nerve for vertebrogenic back pain — experimental, investigational, or unproven (EIU)

Conservative care

required: not stated in the policy
note: n/a — not covered

Trial

required: no
min duration days: not stated in the policy
success criteria: not stated in the policy
threshold is binding: no

Psychological evaluation

required: no
must clear: no
note posture: n/a

Quantity limits

applies: no

Payor-specific notes

Cigna (eviCore CMM-208) deems basivertebral nerve ablation EIU (experimental/investigational/ unproven). DIVERGES from Medicare (LCD/R&N coverage) and Anthem (Carelon coverage); aligns with UHC (also investigational). From the actual fetched eviCore PDF.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Cigna (eviCore CMM-208) deems basivertebral nerve ablation **experimental/investigational/unproven**. No medical-necessity pathway.

.INTRACEPTCIGNA

This patient is a candidate for basivertebral nerve ablation, but BVNA is not a covered
benefit under this plan: Cigna (eviCore CMM-208) deems it experimental, investigational, and
unproven, and there is no medical-necessity pathway. My clinical rationale is documented
here: *** . Alternatives have been discussed with the patient. Any appeal must contest the
EIU determination itself rather than argue medical necessity.

Cautions

For reference: Anthem (Carelon) covers BVNA under Modic criteria; UHC also denies it.
Regenerate if `cigna-commercial-intracept.md` `version` advances.

Prior-auth pathway

required: not stated in the policy
note: n/a — denied as EIU

Provenance

authority:
- type: commercial_policy
- id: Cigna eviCore CMM-208
- title: Ablations/Denervations of Facet Joints and Peripheral Nerves (CMM-208)
- delegated by: Cigna (authored by eviCore / Evernorth)
- applies because: Cigna's eviCore ablation guideline addresses basivertebral nerve ablation
source: https://www.evicore.com/sites/default/files/clinical-guidelines/2025-09/Cigna_CMM-208%20Ablations%20Denerv%20of%20Facet%20Joints%20&%20Peripheral%20Nerves_Final_V2.0.2025_Eff12.18.2025_Pub09.17.2025_1.pdf
archived copy: sources/evicore_cmm208-ablations-bvna_2025-12-18.pdf (sha256 3c61d665147b… — kept in the content repo, not served here)
effective: 2025-12-18 · payor last reviewed: 2025-12-18 · we verified: 2026-07-24 · v1

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Change history

2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
2026-06-29Add commercial Intracept (BVNA) cells: Anthem, UHC, Cigna 6602e687a8