Medicare (CMS LCD/NCD) Intracept Procedure (Basivertebral Nerve Ablation) prior authorization requirements (2026)

Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies

Palmetto GBA LCD L39420 - Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (revision effective ). "Coverage Indications, Limitations, and/or Medical Necessity" section, VERBATIM from the CMS Medicare Coverage Database API on 2026-09-20 (HTML converted to text; nothing paraphrased): Coverage Guidance Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. Low back pain (LBP) is the most expensive occupational disorder in the United States and the leading cause of disability worldwide. 1 Chronic low back pain (cLBP) is defined as persistent pain in the lumbar region lasting for >12 weeks. cLBP has many different etiologies. Research shows evidence that one etiology is associated with degeneration of the vertebral body or vertebral body endplates, resulting in inflammation. The inflammatory response is perceived by the basivertebral nerve (BVN), a sensory nerve that enters the posterior vertebral body and branches out to the superior and inferior endplates. The pain signals are then transmitted to the central nervous system, causing what is known as vertebrogenic pain. 2 Clinically, vertebrogenic pain is generally described as a midline, deep, aching, burning pain that is progressive. Also, it is often associated with an intermittent electrical shock sensation. Vertebrogenic pain is also characterized by absence of radicular expression, lower extremity weakness, or sensory deficits, and the neural tension sign and pain is generally worse with spinal flexion, sitting, standing and general physical activity, when compared to extension. 3,4 Diagnosis of vertebrogenic cLBP focuses on the chronic inflammatory response caused by endplate damage, which is visible on MRI. 5 These signal changes, known as Modic changes (MC), are found in the vertebral body bone marrow that is adjacent to the degenerative endplates. Modic 1 changes indicate inflammation and edema, and Modic 2 changes occur in the setting of marrow ischemia when the red hematopoietic bone marrow has converted into yellow fatty marrow. 6,7,8 Thermal destruction (i.e., ablation) of the intraosseous BVN ( Intracept Procedure) is a therapeutic, interventional surgical procedure used to treat cLBP of vertebrogenic origin. The procedure is performed using fluoroscopic imaging under moderate/conscious sedation or general anesthesia. Radiofrequency energy is applied for 15 minutes at 85 degrees Celsius to produce a lesion to destroy the BVN within the vertebral body. At a minimum, the BVN is ablated in at least 1 vertebral body. Covered Indications Thermal destruction of the intraosseous BVN will be considered medically reasonable and necessary for the treatment of cLBP in patients who meet ALL the following criteria: 1,2,5,9,10,11,12,13 Chronic lumbar back pain of >=6 months duration that causes functional deficit measured on a pain or disability scale*, AND Documented failure to respond to >=6 months of non-surgical management**, AND Absence of non-vertebrogenic pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity, AND Evidence of Type 1 or Type 2 Modic changes on MRI, such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypotensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hypertensive signals (Type 2 Modic change), in 1 or more vertebrae from L3-S1. * Pain assessment and a disability scale must be obtained at baseline to be used for functional assessment. ** Non-surgical management may include but is not limited to: Avoidance of activities that aggravate pain; Trial of Chiropractic manipulation; Trial of Physical Therapy; Cognitive support and recovery reassurance; Injection therapy - epidural and/or facet; Spine biomechanics education; Specific lumbar exercise program; Home use of heat/cold modalities; Low impact aerobic exercise as tolerated; Pharmacotherapy (e.g., non-narcotic analgesics, NSAIDs, muscle relaxants, neuroleptics, and narcotics). Patients must have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to thermal destruction of the intraosseous BVN (such screening must include psychological, as well as, physical evaluation). Documentation of the history and careful screening must be available in the patient chart if requested. Limitations Services that are not reasonable and necessary cannot be covered by Medicare in the following: 1,2,5,9,10,11,12,13 Skeletally immature patients ( Severe cardiac or pulmonary compromise; Active systemic infection or local infection at the intended treatment level; Bleeding diathesis; Pregnancy; Primary radicular pain into the lower extremities (defined as nerve pain following a dermatomal distribution and that correlates with nerve compression on imaging); Previous lumbar/lumbosacral spine surgery at the intended treatment level (with the exception of discectomy/laminectomy if performed >6 months prior to BVN nerve ablation and radicular pain resolved); Primary symptomatic lumbar or lumbosacral spinal stenosis (defined as the presence of neurogenic claudication and confirmed by imaging); Diagnosed osteoporosis (T-score of -2.5 or less), spine fragility fracture history, trauma/compression fracture at the intended treatment level, or spinal cancer; Radiographic evidence of any of the following that correlates with predominant physical complaints: Lumbar/lumbosacral disc extrusion or protrusion >5mm at levels L3-S1; Lumbar/lumbosacral spondylolisthesis > 2mm at any level; Lumbar/lumbosacral spondylolysis at levels L3-S1; Lumbar/lumbosacral facet arthrosis/effusion correlated with facet-mediated pain at levels L3-S1. BMI >40; Advanced generalized systemic disease that limits quality-of-life (QOL) improvements would require a statement of the objective of treatment in such cases; Active, untreated substance abuse disorder. NOTE : Thermal destruction of the intraosseous BVN must only be performed once per vertebral body from L3-S1 per lifetime. Up to 4 vertebral bodies may be treated during 1 procedure. [NEEDS CLINICAL SPOT-CHECK]

Commonly required documentation

• LCD L39420 "Documentation Requirements" section, verbatim:
• Documentation Requirements
• The scales used for measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OSW), Quebec Back Pain Disability Scare (QUE), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.
• The patient's medical record should include but is not limited to:
• The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit,
• Relevant medical history (including a history of chronic vertebrogenic LBP for at least 6 months and failure of non-surgical management of at least 6 months),
• Results of pertinent tests/procedures (including pertinent radiological studies, which must include MRI images and radiology reports of evidence of Modic changes Type 1 or 2 in the L3-S1 vertebral body endplates),
• Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed).
• Notice: Services performed for any given diagnosis must meet all the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, all existing CMS national coverage determinations, and all Medicare payment rules.
• Provider Qualifications:
• Medicare Program Integrity Manual states services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
• Patient safety and quality of care mandate that healthcare professionals who perform thermal destruction of the intraosseous BVN are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program whose core curriculum includes the performance and management of the procedures addressed in this policy. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure, and utilization of the required associated imaging modalities.
• In addition to the above requirements, non-physician providers, such as certified nurse anesthetist, with certain exceptions, may certify, order, and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act
• 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22
• 58 FR 18543, April 7, 2000.) Each practitioner must provide only those services within the scope of practice for each state.
• Definitions
• Chronic low back pain - The temporal definition of pain persisting for greater than or equal to 12 weeks after the onset of the pain.
• Conservative therapy - Appropriate combination of medication (e.g., non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, etc.) in addition to physical therapy, acupuncture (applies to only chronic low back pain), spinal manipulation therapy, cognitive behavioral therapy (CBT), or other interventions individualized to meet the needs of each patient based on the individual's specific presentation, physical findings, and imaging results. This management should include the application of biopsychosocial treatment techniques.
• Disability - Activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.
• Epidural steroid injection - The administration via injection of contrast (absent allergy to contrast), followed by the introduction of steroid medicine into the potential epidural space in the spinal column to deliver steroids to the spinal nerves.
• Impairment - A significant deviation or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease.
• Neurogenic claudication - intermittent leg pain, leg weakness, or leg heaviness from impingement of the nerves emanating from the spinal cord (also called pseuduoclaudication)
• often exacerbated by walking and relieved with leaning forward or sitting down.
• Non-radicular back pain - The radiating non-neuropathic pain which is not causally related to a spinal nerve root irritation and does not produce reproducible neuropathic symptoms in an objective dermatomal pattern.
• Nonspecific low back pain - Back pain that cannot be attributed to a specific disease or spinal pathology.
• Radicular back pain - The radiating neuropathic pain causally related to the spinal nerve root irritation which extends into the distal distribution, typically the lower extremity, producing neuropathic pain in a dermatomal pattern.
• Radiculopathy - Radiating neuropathic pain causally related to the spinal nerve root irritation, which extends distal producing neuropathic pain in a dermatomal pattern.
• Radiculitis - Inflammation of the nerve roots which produces radicular pain without objective neurological findings on physical examination.
• Spinal stenosis - The narrowing of the central spinal canal or foraminal openings, usually due to spinal degeneration that occurs with aging is a radiographic diagnosis. It may also be the result of spinal disc herniation, osteoarthritis, or a tumor. Lumbar spinal stenosis may result in low back pain and pain or abnormal sensations in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control. Neurogenic claudication is often a clinical condition that results from spinal stenosis.
• Regulatory Status
• Intracept Intraosseous Nerve Ablation System
• K190504 - FDA Clearance May 3, 2019

How to submit

• Method: Traditional Medicare: no prior authorization in the office or ASC setting - bill Part B with documentation on file. If performed in a HOSPITAL OUTPATIENT DEPARTMENT, check the CMS OPD prior-authorization list for the specific code before the date of service. Medicare Advantage plans (Humana, UHC, Aetna, Blue Medicare) require their own PA but must apply this LCD's criteria under 42 CFR 422.101(b).

Sources & verification

• BindingSource - LCD: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L40302) · effective 2026-07-15.View
• BindingSource - LCD: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420) · effective 0001-01-01 BC.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

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