Anthem Blue Cross Blue Shield / Elevance (Commercial) · basivertebral nerve ablation

v1verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 6 ticked

Indications

enumerated: yes
covered:
- - name: Vertebrogenic chronic low back pain
  - criteria:
    - skeletally mature: yes
    - chronic lbp min months: 6
    - vas min: 4
    - conservative care failed: >=6 consecutive months supervised conservative care
    - mri modic:
      - Type 1
      - Type 2
    - levels: L3-S1
    - other sources excluded: yes
investigational:
- prior surgery at the target level
- symptomatic spinal stenosis
- spondylolisthesis >2 mm
- disc extrusion >5 mm
- osteoporosis (T-score <= -2.5)
- BMI > 40
- same-day as another spine procedure

Documented pathology (objective basis)required

Conservative care

required: yes
min duration months: 6
satisfied by:
- failed >=6 consecutive months supervised conservative care
- contraindicated
modalities named:
- pharmacologic
- physical therapy
- activity modification

Trial

required: no
min duration days: not stated in the policy
success criteria: not stated in the policy
threshold is binding: no

Psychological evaluation

required: no
must clear: no
note posture: not required (verified — an earlier auto-summary hallucinated a psych gate; not in the Carelon text)

Quantity limits

applies: yes
note: per qualifying level(s) L3-S1; not same-day as another spine procedure

Payor-specific notes

Anthem covers Intracept/BVNA via Carelon (Anthem SURG.00052 removed BVNA mid-2025 and defers to Carelon). Criteria mirror the BVNA standard (Modic 1/2 at L3-S1, chronic LBP >=6 mo with VAS >=4, >=6 mo supervised conservative care) but add explicit anatomic exclusions absent from the Medicare de-facto/LCD standard: prior surgery at level, symptomatic stenosis, spondylolisthesis >2 mm, disc extrusion >5 mm, osteoporosis (T <= -2.5), BMI > 40, and no same-day other spine procedure. No psychological evaluation (verified against the raw Carelon text). Contrast: UHC and Cigna deem BVNA investigational. From the actual fetched Carelon PDF.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from the Anthem-delegated Carelon IPM guideline only (Anthem SURG.00052 removed BVNA and defers to Carelon). Do NOT start from the Medicare phrase: the Medicare radicular-pain lookback and lifetime vertebral-body cap are NOT Anthem criteria and must not appear here.

.INTRACEPTANTHEM

.INTRACEPTANTHEM

Assessment: *** — vertebrogenic chronic low back pain of >=6 months duration, VAS >=4 on
most days, with other sources of low back pain excluded. MRI *** demonstrates Type 1 and/or
Type 2 Modic endplate changes at >=1 vertebral endplate, level(s) *** within L3-S1.

Medical necessity per Carelon MSK01-0626.1 (the Anthem-delegated Carelon IPM guideline): the
patient is skeletally mature, and supervised conservative care — pharmacologic therapy,
physical therapy, and activity modification — has failed over >=6 consecutive months: *** ,
or was contraindicated. None of the Carelon exclusions apply: no prior surgery at the target
level, no symptomatic spinal stenosis, no spondylolisthesis >2 mm, no disc extrusion >5 mm,
no osteoporosis (T-score <=-2.5), BMI is not >40, and no other spine procedure is being
performed the same day. MRI and conservative-care documentation are on file.

Plan: Intracept basivertebral nerve ablation — CPT 64628 and 64629 for additional levels —
at qualifying level(s) *** within L3-S1. Coverage is scoped per qualifying level, and the
procedure is not performed the same day as another spine procedure. Risks, benefits, and
alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

diagnosis line (VAS >=4 most days; Modic 1/2 at >=1 endplate L3-S1; CLBP >=6 months; no Medicare 12-month radicular-pain lookback)
conservative-care line (>=6 CONSECUTIVE months supervised — binding; no modality-count floor)
exclusions line (Carelon anatomic/clinical exclusion list — absent from Medicare)
plan/quantity line (per qualifying level L3-S1; no Medicare lifetime <=4-body cap)

Cautions

Carelon Medical Benefits Management prior authorization required (Anthem delegates BVNA review to Carelon). No psychological evaluation and no trial phase apply — psych eval verified absent from the Carelon text. Regenerate if `anthem-commercial-intracept.md` `version` advances past `source_version` above.

Prior-auth pathway

required: yes
pathway: Carelon Medical Benefits Management

Provenance

authority:
- type: commercial_policy
- id: Carelon MSK01-0626.1
- title: Carelon Interventional Pain Management — Basivertebral Nerve Ablation
- delegated by: Anthem / Elevance Health
- applies because: Anthem SURG.00052 was revised (eff 2025-07-01) to REMOVE BVNA and defer to Carelon; the Carelon IPM guideline now governs
source: https://guidelines.carelonmedicalbenefitsmanagement.com/wp-content/uploads/2026/03/PDF-Interventional-Pain-Management-2026-06-14.pdf
archived copy: sources/carelon_interventional-pain-mgmt_2026-06-14.pdf (sha256 70ebcaf53e7b… — kept in the content repo, not served here)
effective: 2026-06-14 · payor last reviewed: 2026-06-14 · we verified: 2026-07-24 · v1

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Change history

2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
2026-06-29Add commercial Intracept (BVNA) cells: Anthem, UHC, Cigna 6602e687a8