Medicare (CMS LCD/NCD) Intracept Procedure (Basivertebral Nerve Ablation) prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629), for Medicare (NY) plans. Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
NEWLY COVERED IN NEW YORK - LCD effective 07/15/2026. Thermal destruction of the intraosseous basivertebral nerve is covered for chronic low back pain when ALL are met: (1) chronic lumbar back pain of >= 6 MONTHS causing functional deficit measured on a pain or disability scale; (2) documented failure to respond to >= 6 MONTHS of non-surgical management (may include activity modification, chiropractic, physical therapy, cognitive support, epidural and/or facet injection therapy, spine biomechanics education, a specific lumbar exercise program, heat/cold, low-impact aerobic exercise and pharmacotherapy); (3) absence of non-vertebrogenic pathology on clinical assessment or imaging that could explain the pain (fracture, tumor, infection, significant deformity); and (4) Type 1 or Type 2 MODIC CHANGES on MRI in one or more vertebrae from L3-S1. The patient must have undergone careful multidisciplinary screening including BOTH psychological and physical evaluation, documented and available in the chart on request. NOT COVERED: age <= 18; severe cardiac or pulmonary compromise; active systemic or local infection at the treatment level; bleeding diathesis; pregnancy; primary radicular pain in a dermatomal distribution correlating with nerve compression on imaging; previous lumbar surgery at the intended level (except discectomy/laminectomy performed > 6 months prior with radicular pain resolved); primary symptomatic lumbar stenosis with neurogenic claudication confirmed on imaging; diagnosed osteoporosis with T-score <= -2.5, spine fragility-fracture history, trauma/compression fracture at the level, or spinal cancer; BMI > 40; active untreated substance use disorder; advanced generalized systemic disease limiting quality-of-life gain (requires a stated treatment objective); and radiographic findings correlating with the predominant complaint - disc extrusion or protrusion > 5 mm at L3-S1, spondylolisthesis > 2 mm at any level, spondylolysis at L3-S1, or facet arthrosis/effusion correlated with facet-mediated pain at L3-S1. May be performed only ONCE per vertebral body. [NEEDS CLINICAL SPOT-CHECK]
Commonly required documentation
- MRI report explicitly naming Type 1 or Type 2 Modic changes and the involved levels (L3-S1)
- a 6-month non-surgical management record
- baseline pain AND disability scale
- documented multidisciplinary screening including a psychological evaluation
- and affirmative documentation excluding each listed contraindication - in particular BMI, T-score, spondylolisthesis measurement and disc protrusion size.
How to submit
- Method: No prior authorization in the office or ASC setting - bill Part B with documentation on file. Confirm the current CPT assignment (64628 first two vertebral bodies including imaging, +64629 each additional) and check the CMS OPD prior-authorization list if performed in a hospital outpatient department.
Sources & verification
- BindingSource — LCD: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L40302) · effective 2026-07-15.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 2026-08-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Intracept Procedure (Basivertebral Nerve Ablation)?
Based on the cited policy, Medicare (CMS LCD/NCD) does not generally require prior authorization for Intracept Procedure (Basivertebral Nerve Ablation) (CPT 64628, 64629). Confirm with Medicare (CMS LCD/NCD), as this can vary by plan.
What does Medicare (CMS LCD/NCD) require to approve Intracept Procedure (Basivertebral Nerve Ablation)?
NEWLY COVERED IN NEW YORK - LCD effective 07/15/2026. Thermal destruction of the intraosseous basivertebral nerve is covered for chronic low back pain when ALL are met: (1) chronic lumbar back pain of >= 6 MONTHS causing functional deficit measured on a pain or disability scale; (2) documented failure to respond to >= 6 MONTHS of non-surgical management (may include activity modification, chiropra… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Intracept Procedure (Basivertebral Nerve Ablation) to Medicare (CMS LCD/NCD)?
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.