Blue Cross NC Intracept Procedure (Basivertebral Nerve Ablation) prior authorization requirements (2026)
What Blue Cross NC generally requires to approve Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629), for Commercial plans. Yes. Blue Cross NC generally requires prior authorization for Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629).
Medical-necessity criteria Blue Cross NC generally applies
Intraosseous Basivertebral Nerve Ablation - "Thermal destruction of the lumbar intraosseous basivertebral nerve (BVN) may be considered medically necessary for the treatment of select chronic low back pain in patients who meet ALL the following criteria: Skeletally mature patient; History of chronic lumbar back pain for at least 6 months with a minimum VAS score of >= 4 on most days; Documented failure to respond to at least 6 consecutive months of supervised non-surgical conservative management (for example, exercise, nonsteroidal and/or steroidal medication [unless contraindicated], physical therapy, including passive and active treatment modalities, and activity/lifestyle modification); All other possible pain sources including, but not limited to, fracture, tumor, infection, or significant spinal deformity have been ruled out; Imaging studies confirm BOTH of the following: Magnetic resonance imaging (MRI)-demonstrated Modic Type 1 or 2 changes in at least one vertebral endplate, at one or more levels from L3 to S1 ...; Absence of non-vertebrogenic pathology that could explain the source of the patient's pain including, but not limited to, fracture, tumor, or infection." "BVN ablation may not be combined with any other spine procedure on the same day." [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- VAS scores documenting >= 4 on most days for >= 6 months
- dated record of >= 6 consecutive months of supervised conservative management
- MRI report describing Modic Type 1 or 2 endplate changes at L3-S1
- documentation excluding fracture, tumor, infection, deformity, radicular pain, symptomatic stenosis, spondylolisthesis > 2 mm and spondylolysis.
Situations to verify before submitting
Blue Cross NC may not cover Intracept Procedure (Basivertebral Nerve Ablation) in these situations. Verify against the current policy rather than assuming a denial:
- {"text":"Exclusions/Contraindications: \"Skeletally immature patients (generally <18 years of age); Patients with severe cardiac or pulmonary compromise; Concurrent vertebral augmentation procedures at the intended levels; MRI evidence of Modic changes at levels other than L3-S1; Radicular pain ...; Previous lumbar spine surgery at the intended treatment level (discectomy/laminectomy allowed if > 6 months prior to baseline and radicular pain resolved); Symptomatic spinal stenosis ...; Diagnosed osteoporosis (T-score of -2.5 or less), metabolic bone disease, spine fragility fracture history, or trauma/compression fracture at intended level, or spinal cancer; Spine infection, active systemic infection, bleeding diathesis; Radiographic evidence of other pain etiology: Disc extrusion or protrusion > 5 mm at levels L3-S1; Spondylolisthesis > 2 mm at any level; Spondylolysis at any level; Facet arthrosis/effusion correlated with facet-mediated LBP at levels L3-S1; Current use of extended-release opioids with addiction behaviors; BMI > 40; Contraindicated to MRI, allergies to components of the device, or active implantable devices; Pregnant or lactating women; Repeat procedure at the same level of a prior intraosseous ablation.\"","source":"https://guidelines.carelonmedicalbenefitsmanagement.com/interventional-pain-management-2026-06-14/"}
How to submit
- Method: Prior authorization is delegated to Carelon Medical Benefits Management for spine surgery, joint surgery, interventional pain management, and small joint surgery (Commercial Fully Insured since 2023-10-01; ASO groups only if the group elected the program, effective 2025-01-01 - verify by member ID on the Carelon portal or via the number on the member ID card). Submit through the Carelon Provider Portal via Blue e (24/7, real-time against Carelon clinical guidelines) or by phone at 866-455-8414, Monday-Friday 8 a.m.-6 p.m. ET. Applies in both outpatient and inpatient admission settings. Since 2025-07-01 (Fully Insured only; excludes Medicare Advantage, DSNP, EGWP, FEP and ASO), a request for a hospital-based OUTPATIENT setting for interventional pain or joint-arthroscopy/small-joint procedures gets an additional site-of-care review.
- Portal: Carelon Provider Portal (via Blue e)
- Typical turnaround: about 3 days
Sources & verification
- BindingSource - Carelon Clinical Appropriateness Guidelines: Interventional Pain Management (Interventional Pain Management 2026-06-14) · effective 2026-06-14.View
- BindingSource - Blue Cross NC Musculoskeletal Program and Interventional Pain Management effective October 1, 2023 (Carelon delegation) (Provider news 2023-10-01) · effective 2023-10-01.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-09-20.
Frequently asked questions
Does Blue Cross NC require prior authorization for Intracept Procedure (Basivertebral Nerve Ablation)?
Yes. Blue Cross NC generally requires prior authorization for Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629).
What does Blue Cross NC require to approve Intracept Procedure (Basivertebral Nerve Ablation)?
Intraosseous Basivertebral Nerve Ablation - "Thermal destruction of the lumbar intraosseous basivertebral nerve (BVN) may be considered medically necessary for the treatment of select chronic low back pain in patients who meet ALL the following criteria: Skeletally mature patient; History of chronic lumbar back pain for at least 6 months with a minimum VAS score of >= 4 on most days; Documented fa… Always confirm against the current Blue Cross NC policy.
How long does a Blue Cross NC prior authorization take?
Blue Cross NC typically decides Intracept Procedure (Basivertebral Nerve Ablation) requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Intracept Procedure (Basivertebral Nerve Ablation) to Blue Cross NC?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.