CurrentCareSource GeorgiaPolicy MP-MM-1376

Intraosseous Basivertebral Nerve Ablation

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Defines CareSource Georgia coverage criteria for intraosseous basivertebral nerve ablation (e.g., Intracept) to treat vertebrogenic chronic low back pain and specifies when the procedure is medically necessary, not medically necessary, and reimbursement limitations for members covered by CareSource (Georgia and listed marketplaces).

Policy Summary

PayerCareSource Georgia

PolicyIntraosseous Basivertebral Nerve Ablation

Policy CodePolicy MP-MM-1376

Change TypeNo material change

Effective DateMar 1, 2026

Last ReviewDec 2, 2025

Next Review DateN/A

Key ActionObtain prior authorization and ensure documentation of ≥6 months CLBP, required conservative therapy completion, MRI showing Modic Type I/II at L3–S1, and use of an FDA-approved device.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=6 moPain duration (min)

>=6 wkActive therapy (min)

L3-S1Modic levels

10 mmSafety distance

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