Clinical Review Criteria — Basivertebral Nerve Ablation (Intracept)
Clinical review criteria governing coverage and medical necessity determinations for basivertebral (intraosseous) nerve ablation (e.g., Intracept) for chronic low back pain for Kaiser Permanente Washington members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage by beneficiary type
Coverage determination differs by beneficiary type:
See referenced Medicare LCD L39642 and Billing and Coding article A59466 for detailed criteria
Non‑Medicare requests will be denied unless policy position changes.
Key clinical trials that informed the evidence review excluded patients with symptomatic spinal stenosis, radiculopathy, disk protrusion, or spondylolisthesis; these diagnoses therefore represent important exclusions when interpreting study applicability and selecting candidates for therapy. (Trials enrolled patients with treatment‑refractory chronic low back pain and MRI‑detected Modic type 1 or 2 changes.)
The MTAC evidence summary found low‑certainty evidence of improvements in pain, function, and quality of life after basivertebral nerve ablation but noted that benefits were not consistently superior to sham at early follow‑up; complication rates in studies ranged from 2.7% to 25%, and common adverse events included postoperative leg pain related to pedicle breach. These trial designs and reported complication patterns are relevant caveats when extrapolating study results to broader clinical populations.
For non‑Medicare members, basivertebral nerve ablation is considered Not Medically Necessary due to insufficient evidence in the published literature demonstrating that the procedure is as safe and effective as standard therapies or provides better long‑term outcomes.
As a result, requests for this service for non‑Medicare beneficiaries will be denied under current policy unless the coverage position is changed based on new evidence or guidance.
Coding
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure). |
Provider Actions and Authorization
Prior authorization / coding headline (CPT 64628, 64629)
For Medicare members, basivertebral nerve ablation (CPT 64628, 64629) is considered medically necessary when the applicable Medicare policy statements (LCD/LCA) criteria are met; non‑Medicare members are considered Not Medically Necessary.
Conservative therapy prerequisite
The Intracept procedure is indicated for patients who have not had adequate pain relief with conservative therapy; conservative treatments must have been attempted prior to consideration of basivertebral nerve ablation.
- Documented failure of adequate pain relief with conservative therapy prior to considering BVN ablation.
Required documentation — last 6 months of clinical notes
When requesting review for this service, submit clinical documentation including the last 6 months of clinical notes from the requesting provider and/or specialist.
- Provide the most recent 6 months of progress notes, treatment history, and specialist evaluations to support medical necessity.
Non‑Medicare requests: Not Medically Necessary (denial trigger)
Requests for basivertebral nerve ablation for non‑Medicare members are considered Not Medically Necessary and will be denied due to insufficient evidence of safety and long‑term effectiveness compared with standard therapies.
- Non‑Medicare coverage stance: Not Medically Necessary — denials will be issued unless policy position changes.
Background
Basivertebral nerve ablation (BVN; e.g., the Intracept System) is a minimally invasive, fluoroscopically guided transpedicular radiofrequency procedure intended to ablate the intraosseous basivertebral nerve and thereby reduce vertebrogenic chronic low back pain.
The procedure is performed using the Intracept introducer and curved cannula to reach the vertebral body via a transpedicular approach; a radiofrequency probe is then placed to thermally ablate the basivertebral nerve. It is intended for patients with treatment‑refractory chronic low back pain, often with MRI‑detected Modic type 1 or 2 changes, and is typically performed in the outpatient setting under fluoroscopic guidance.
Definitions
Conservative Treatment Requirements
Conservative therapies attempted prior to consideration
Covered when ALL of the following conservative therapies have been attempted without adequate pain relief:
Conservative treatment must have been attempted; Intracept is intended for patients who have not had adequate pain relief with conservative therapy.
Frequency Limits
Imaging Requirements
MRI requirement — Modic type 1 or 2 changes (when present in trial inclusion)
Magnetic resonance imaging demonstrating Modic type 1 or type 2 changes was a key inclusion criterion in the identified studies and is listed by the manufacturer as a key indication; MRI evidence of Modic 1 or 2 changes should be considered when present in trial inclusion.
- Document MRI findings of Modic type 1 or 2 changes when available to support candidate selection.
Not Covered
Requests for basivertebral nerve ablation for non‑Medicare members are classified as Not Medically Necessary and will be denied under the current policy due to insufficient evidence of safety and long‑term effectiveness compared with standard treatments.
Providers submitting requests for this procedure for non‑Medicare beneficiaries should expect denial and may consider alternative, evidence‑based conservative and interventional therapies consistent with standard care pathways.
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