CurrentBlue Cross Blue Shield - LouisianaPolicy MA-238

Immersive Virtual Reality Therapy for Chronic Lower Back Pain

Customize your policy alerts

Sign up for blue cross blue shield - louisiana Policy MA-238 alerts

Get alerted when Policy MA-238 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage policy for FDA-authorized prescription digital therapeutics using dedicated immersive virtual reality hardware and software to manage chronic lower back pain.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyImmersive Virtual Reality Therapy for Chronic Lower Back Pain

Policy CodePolicy MA-238

Change TypeNo material change

Effective DateDecember 1, 2026

Last ReviewSep 15, 2026

Next Review DateSeptember 1, 2027

Key ActionObtain prior authorization for all listed codes before services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentBlue Cross Blue Shield - LouisianaPolicy MA-238

Immersive Virtual Reality Therapy for Chronic Lower Back Pain

Customize your policy alerts

Sign up for blue cross blue shield - louisiana Policy MA-238 alerts

Get alerted when Policy MA-238 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage policy for FDA-authorized prescription digital therapeutics using dedicated immersive virtual reality hardware and software to manage chronic lower back pain.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyImmersive Virtual Reality Therapy for Chronic Lower Back Pain

Policy CodePolicy MA-238

Change TypeNo material change

Effective DateDecember 1, 2026

Last ReviewSep 15, 2026

Next Review DateSeptember 1, 2027

Key ActionObtain prior authorization for all listed codes before services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance

3Scope requirements

2021FDA authorization year

8 weeksProgram duration

100%Codes requiring prior authorization

90 daysTransition authorization period

Coverage Criteria

Products within policy scope

A product is within the scope of this review only when all of the following are met.

Scope requirements

PDT: The product must be a prescription digital therapeutic in which software performs one or more medical purposes as the primary therapeutic component of a hardware-software system; software used solely to store or transmit medical information is excluded.
FDA authorization: The product must have received marketing clearance or approval from the U.S. Food and Drug Administration.
Prescription: The product must be prescribed by a healthcare provider.

Not covered as investigational

The policy considers the service investigational and does not provide coverage.

Investigational coverage stance: Prescription virtual reality digital therapeutics for chronic lower back pain, including RelieVRx, are considered investigational because the available evidence is insufficient to determine improvement in net health outcome.

Coverage is not available for investigational medical treatments or procedures, drugs, devices, or biological products.

Investigational medical treatments, procedures, drugs, devices, and biological products are excluded from coverage. The policy considers FDA-authorized prescription virtual reality digital therapeutics for chronic lower back pain, including RelieVRx, to be investigational. Limited exceptions may apply for qualifying IDE studies, including routine services for Category A IDE studies and devices and related services for Category B IDE studies when not supplied by the trial sponsor.

Federal and state law take precedence when determining eligibility for coverage. Applicable health insurance contract language, definitions, specific contract provisions, and exclusions must also be considered before this Medical Policy. If the contract contains language that differs from the policy definition, the contract language is relied upon for the specific coverage determination.

Coding and Product Identifiers

HCPCS Level II codeHCPCS

E1905

Virtual reality cognitive behavioral therapy device (cbt), including pre-programmed therapy software

FDA Product Codemixed

QRA	FDA product code for RelieVRx

FDA Authorizationmixed

DEN210014

De Novo marketing authorization for EaseVRx, subsequently renamed RelieVRx

CPTCPT

0770T

CPT code associated with services under this policy

HCPCSHCPCS

E1905

HCPCS code associated with services under this policy

ICD-10 DiagnosisICD-10

N/A	No ICD-10 diagnosis code specified

Provider and Authorization Actions

Prior Authorization

Prior Authorization Required

All codes listed in this Medical Policy require prior authorization to support appropriate utilization and alignment with current clinical guidelines.

Prior authorization applies to all codes listed in the policy.

Documentation Required

Documentation for Transition Authorization

For an ongoing course of treatment authorized by a previous health plan, Blue Advantage may honor the authorization for the same service under the same type of in-network benefit during a 90-day transition period. The member or provider must provide documentation of the previous health plan’s authorization, and the services must otherwise be covered under the Blue Advantage plan.

Applicable transition period: 90 days.
Required documentation: authorization for the ongoing course of treatment from the previous health plan.

Policy Background

This policy addresses prescription digital therapeutics that use dedicated immersive virtual reality hardware and proprietary software to deliver treatment for chronic lower back pain. RelieVRx, formerly known as EaseVRx, provides an 8-week, self-administered at-home behavioral skills program incorporating cognitive behavioral therapy and other evidence-based behavioral methods. Although some studies reported improvements in pain outcomes, available evidence is insufficient to establish improvement in net health outcomes under this policy.

Definitions

Prescription digital therapeutic (PDT)

DefinitionSoftware that performs one or more medical purposes as the primary therapeutic component of a hardware-software system.

Excluded softwareSoftware used solely to store or transmit medical information is excluded.

Policy applicationFor this policy, the PDT must use dedicated hardware, including a VR headset, to deliver the primary therapeutic intervention.

RelieVRx

ProductRelieVRx is a prescription-use immersive VR system for pain management.

Therapeutic methodsIt provides cognitive behavioral therapy and other evidence-based behavioral methods, including mindfulness, relaxation training, and interoceptive awareness techniques.

Not Covered Services

Prescription virtual reality digital therapeutics for chronic lower back pain, including RelieVRx, are considered investigational and are not covered. This coverage determination applies to FDA-authorized prescription virtual reality digital therapeutics within the scope of the policy.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyImmersive Virtual Reality Therapy for Chronic Lower Back Pain

Policy CodePolicy MA-238

Change TypeNo material change

Effective DateDecember 1, 2026

Last ReviewSep 15, 2026

Next Review DateSeptember 1, 2027

Key ActionObtain prior authorization for all listed codes before services are provided.

SourceLink

On This Page

The authorization must be for the same service and the same type of in-network benefit.

Denial Risk

Investigational VR Therapy

Coverage is not available for investigational medical treatments or procedures, drugs, devices, or biological products. FDA-authorized prescription virtual reality digital therapeutics for chronic lower back pain, such as RelieVRx, are considered investigational under this policy, so coverage is denied or unavailable unless an applicable CMS exception or mandate applies.

Investigational services are not covered unless mandated by the Centers for Medicare and Medicaid Services.
Routine services for Category A IDE studies and devices and related services for Category B IDE studies may be covered when not supplied by the trial sponsor.

Denial Risk

Insufficient Evidence of Net Health Benefit

The evidence is insufficient to determine that immersive virtual reality therapy for chronic lower back pain improves the net health outcome. Divergent trial results, limited population diversity, and the absence of clinically meaningful effects in an adequately powered independent trial support the policy’s investigational determination.

Earlier trials showed modest effects that did not meet thresholds for clinical importance.
An independent federally funded RCT found no significant superiority over sham VR and detected no clinically meaningful effect.
The uncertainty includes whether earlier therapeutic signals were driven by immersion and distraction rather than the distinguishing cognitive behavioral therapy content.

Program descriptionThe program is delivered through a VR headset as an 8-week, self-administered, at-home behavioral skills-based treatment for chronic lower back pain.

AbbreviationVR means virtual reality.

Delivery formatIn this policy, VR refers to immersive visual experiences delivered through a dedicated VR headset.

Use in therapyThe immersive VR system delivers behavioral methods for pain management.

CBT

AbbreviationCBT means cognitive behavioral therapy.

Role in RelieVRxCBT is one of the evidence-based behavioral methods provided by RelieVRx.

Delivery methodCBT is delivered through immersive VR experiences as part of the pain-management program.

Investigational

Core definitionA treatment, procedure, drug, device, or biological product is investigational when its effectiveness has not been clearly tested and it has not been incorporated into standard medical practice.

Regulatory considerationThe determination considers whether the item can be lawfully marketed without FDA approval and whether FDA approval has been granted when the item is furnished.

Evidence standardThe determination considers whether further studies or clinical trials are needed to establish maximum tolerated dose, toxicity, safety, effectiveness, comparative effectiveness, or improvement in health outcomes.

Relevant evidenceRelevant evidence may include consultation with technology evaluation centers, credible peer-reviewed medical literature recognized by the relevant medical community, and federal regulations.

Medically necessary

Core definitionHealth care services, treatments, procedures, equipment, drugs, devices, items, or supplies that a prudent provider would provide to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms.

Practice standardThe service must conform to nationally accepted standards of medical practice.

Clinical appropriatenessThe service must be clinically appropriate in type, frequency, extent, level of care, site, and duration, and considered effective for the patient's illness, injury, or disease.

Cost and purpose limitsThe service must not be primarily for personal comfort or convenience and must not be more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.