CurrentMass General Brigham Health PlanPolicy N/A

Medical Policy Interventional Pain Management of the Spine

Defines medical necessity, prior authorization requirements, Medicare/MassHealth/OneCare/SCO variations, and exclusions for epidural steroid injections, facet joint injections, and basivertebral nerve ablation (BVNA) for Mass General Brigham Health Plan members aged ≥18 (BVNA criteria apply to ≥25 in plan-specific customization).

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Interventional Pain Management of the Spine

Policy CodePolicy N/A

Change TypeCombined policies; BVNA criteria revised; PA table updated

Effective Date2025-08

Next Review Date

Key ActionProviders must use Mass General Brigham Health Plan procedures for prior authorization and document that requests meet the plan's customized InterQual criteria via the provider website InterQual/Criteria Lookup.

SourceLink

POLICY UPDATE CHANGES

Combined former Epidural Steroid Injections and Basivertebral Nerve Ablation policies and added medical necessity guidelines for facet joint injection.

Replaced BVNA criteria and exclusions with reference to customized InterQual subset (October 2025).

Updated prior authorization table and added variation for OneCare and SCO members (January 2026 ad hoc review).

3Procedures addressed

15BVNA exclusion conditions

>=25

BVNA minimum age (customized)

Coverage Summary

Scope: This policy addresses medical necessity, prior authorization requirements, and plan-specific variations for interventional spine procedures including epidural steroid injections, facet joint injections, and basivertebral nerve ablation (BVNA) for Mass General Brigham Health Plan members.

Subject and procedures addressed: Interventional pain management of the spine (epidural steroid injections, facet joint injections, BVNA), using Mass General Brigham Health Plan’s customized InterQual criteria to determine medical necessity.

Customization and plan variations: The policy leverages and customizes InterQual criteria for each procedure (epidural steroid injections, facet joint injections, BVNA) and includes plan-specific variations for MassHealth, Medicare Advantage, OneCare, and SCO members as described in the policy.

Effective and review dates: Effective August 2025 (combined policies and added facet joint injection guidance); the policy notes ad hoc updates in October 2025 and January 2026 and lists the most recent review activity (ad hoc reviews in October 2025 and January 2026).

Customized thresholds and statistics

Facet injection pain reduction threshold50% pain reduction required for approval (customized from 80%)

Facet injection minimum interval2 weeks between injections (customized from 3 weeks)

BVNA minimum age>= 25 years (customized InterQual allowance)

Procedures addressed3 (epidural steroid injection, facet joint injection, BVNA)

Explicit BVNA exclusion conditions15 listed conditions

Medical Necessity Criteria

Epidural Steroid Injections - Medical Necessity

Medical necessity for epidural steroid injection for members 18 years of age or older is determined through InterQual criteria customized by Mass General Brigham Health Plan.

Age: Member is 18 years of age or older
InterQual Determination: Medical necessity determined by InterQual criteria customized by Mass General Brigham Health Plan
Provider must access customized InterQual criteria via MassGeneralBrighamHealthPlan.org InterQual Criteria Lookup

Facet Joint Injections - Medical Necessity

Medical necessity for facet joint injections for members 18 years of age or older is determined through InterQual criteria customized by Mass General Brigham Health Plan.

BVNA Exclusions (Experimental / Investigational)

BVNA - Exclusions (Considered Experimental/Investigational)

BVNA is experimental and investigational when ANY of the following conditions is present:

Radicular pain
Previous lumbar spine surgery
Symptomatic spinal stenosis
Active infection: Spine infection or other active systemic infection
Osteoporosis or metabolic bone disease:

Coding

Informational procedure codes included in policyCPT

62320	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Injection(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62322	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Injection(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance
62324	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62326	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid; lumbar or sacral (caudal); without imaging guidance
62327	Injection(s), including indwelling catheter placement, interlaminar epidural or subarachnoid; lumbar or sacral (caudal); with imaging guidance
64479	Injection(s), transforaminal epidural, with (anesthetic and/or steroid)
64480	Transforaminal epidural with imaging guidance, cervical or thoracic, each additional level

1–10 of 20

1/2

Provider Actions / Prior Authorization

Prior Authorization

Prior authorization required (varies by plan)

Authorization required for Interventional Pain Management of the Spine for Commercial, MassHealth, Medicare Advantage, OneCare, and SCO in specified cases; providers must use Mass General Brigham Health Plan procedures for PA submission and reference the InterQual customized criteria.

Affected plans: Commercial, MassHealth, Medicare Advantage, OneCare, SCO
Use Mass General Brigham Health Plan prior authorization procedures for submission and reference the customized InterQual criteria via the provider website

Documentation Required

Use of InterQual customized criteria

Providers must access and document that requests meet Mass General Brigham Health Plan's customized InterQual criteria via the provider website InterQual/Criteria Lookup to support medical necessity determinations.

Background, Evidence, and Definitions

Background: Mass General Brigham Health Plan’s coverage criteria align with and customize InterQual proprietary clinical criteria to determine medical necessity for epidural steroid injections, facet joint injections, and BVNA; the policy also aligns with CMS National and Local Coverage Determinations (LCDs/NCDs) and uses MassHealth guidance where applicable for MassHealth ACO members.

Evidence summary: The policy cites randomized controlled trials and longer-term studies (Fischgrund et al. 2018; Khalil et al. 2019; Koreckij et al. 2021) and society guidance (ASPN best-practice guidelines) showing significant and sustained pain reduction, improved function, and acceptable safety for appropriately selected patients undergoing BVNA, supporting its medical necessity when InterQual-based criteria and plan-specific requirements are met.

Study/Label	Key finding
Randomized controlled trial (Fischgrund et al. 2018)	Demonstrated significant reductions in pain and improvements in function versus sham for BVNA
Khalil et al. 2019	Multicenter randomized study confirming sustained pain relief and functional improvements after BVNA
Koreckij et al. 2021	24-month results showing sustained efficacy and minimal complications following BVNA

Term	Definition
BVNA	Basivertebral nerve ablation / thermal destruction of intraosseous basivertebral nerve
InterQual	Proprietary clinical criteria used to determine medical necessity, customized by Mass General Brigham Health Plan in this policy

Medicare LCDs / Determinations

Type	Name	Number
LCD	Epidural Steroid Injections for Pain Management	L39015 / L33906 / L39240 / L39242 / L36920 / L38994 / L39054
LCD	Facet Joint Interventions for Pain Management	L38773 / L33930 / L35936 / L38801 / L38803 / L34892 / L38765 / L38841
LCD	Intraosseous Basivertebral Nerve Ablation / Thermal Destruction of BVN	L39642 / L39644 / L39420

Revision History

August 2025material

Effective August 2025 combined prior separate policies; simplified description of customized InterQual subset for epidural steroid injections; added MassHealth variation for BVNA. (Combined former Epidural Steroid Injections and Basivertebral Nerve Ablation policies and added medical necessity guidelines for facet joint injection.)

October 2025material

Replaced BVNA criteria and exclusions with reference to customized InterQual subset (neuroablation, percutaneous -> vertebrogenic back pain pathway); customization allows age >=25.

January 2026non-materialLatest

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Interventional Pain Management of the Spine

Policy CodePolicy N/A

Change TypeCombined policies; BVNA criteria revised; PA table updated

Effective Date2025-08

Next Review Date

SourceLink

On This Page

Age: Member is 18 years of age or older

InterQual Determination: Medical necessity determined by InterQual criteria customized to allow approval for 50% pain reduction rather than 80%

Provider must access customized InterQual criteria via MassGeneralBrighamHealthPlan.org InterQual Criteria Lookup

Basivertebral Nerve Ablation (BVNA) - Medical Necessity

Medical necessity for basivertebral nerve ablation (BVNA) is determined through InterQual criteria customized by Mass General Brigham Health Plan.

BVNA - Medical Necessity

InterQual Pathway: Member meets InterQual criteria in the 'neuroablation, percutaneous' subset selecting the 'vertebrogenic back pain' pathway
Age: Member is 25 years of age or older (customized)
Provider must access customized InterQual criteria via MassGeneralBrighamHealthPlan.org Criteria Lookup

Osteoporosis, metabolic bone disease, or history of spine fragility fracture

Recent vertebral fracture: Vertebral fracture within the past year

Spinal malignancy: Malignancy of the spine

Spondylolisthesis >2 mm: Spondylolisthesis greater than 2 mm

Spondylolysis at any level

BMI >40: BMI greater than 40

Uncontrolled psychiatric disease: Poorly controlled major psychiatric disease suspected to be a major contributor to back pain

Bedbound or impaired mobility: Bedbound or a neurologic condition that prevents early mobility

Vertebrae outside L3–S1: Treatment of vertebrae above L3 or below S1

Repeat BVNA on same vertebra: Repeat BVNA on a vertebra that has previously been treated with BVNA

Concurrent procedures: Performed concurrently with other procedures, including steroid injections, nerve blocks, ablation of other nerves, and surgeries

The policy states that BVNA is considered experimental and investigational when ANY of the listed exclusion conditions is present (for example, radicular pain, prior lumbar surgery, symptomatic spinal stenosis, recent vertebral fracture, BMI > 40, pregnancy, treatment outside L3–S1, concurrent procedures, etc.), and that presence of any such exclusion may render the request not payable and lead to denial.

Rationale: this exclusion framework is supported by the policy’s evidence summary and cited clinical trials and guidelines which define appropriate patient selection for BVNA and support its use only in selected patients who meet established criteria.

Document InterQual criteria lookup and determination via MassGeneralBrighamHealthPlan.org InterQual/Criteria Lookup on the provider website

Denial Risk

BVNA excluded conditions risk of denial

Requests for BVNA will be considered experimental/investigational (and thus not payable) when any exclusion condition is present (list of exclusions), which may lead to denial.

See the BVNA exclusion list in the policy (radicular pain; prior lumbar surgery; symptomatic spinal stenosis; infection; osteoporosis or fragility fracture history; recent vertebral fracture; spinal malignancy; spondylolisthesis >2 mm; spondylolysis; BMI >40; poorly controlled major psychiatric disease; bedbound or neurologic conditions preventing early mobility; pregnancy; treatment of vertebrae above L3 or below S1; repeat BVNA on previously treated vertebra; concurrent procedures)

Updated prior authorization table and added variation for OneCare and SCO members (ad hoc review).