HumanaChoice (Medicare Advantage, PPO) · all interventional pain

.INTRACEPTMCARE

Assessment: *** — vertebrogenic chronic low back pain, predominantly axial in the ___
region, present >=6 months with functional deficit (baseline pain/disability scale ***).
Low back pain is the dominant symptom and there is no primary radicular pain — no dermatomal
pain correlating with nerve compression on imaging. MRI *** demonstrates Type 1 and/or Type 2
Modic endplate changes at *** (within L3-S1), and the pain localizes to those levels.

Medical necessity under Medicare's reasonable-and-necessary standard (no NCD or LCD binds in
IN/KY; documented to the peer-MAC BVNA standard): the patient is skeletally mature (>18).
Non-surgical management has been tried and has failed over >=6 months across >=3 modalities —
activity modification, physical therapy / professionally-directed exercise, and
pharmacotherapy with analgesics, muscle relaxants, and anti-inflammatories: *** — or was
contraindicated. Alternative primary pain generators are excluded: no fracture, tumor,
infection, or significant deformity, and no symptomatic stenosis, disc extrusion >5 mm,
spondylolisthesis >2 mm, or correlated facet arthrosis at the level. No exclusion applies —
no prior surgery at the level (a discectomy or laminectomy >6 months prior with resolved
radicular pain excepted), no osteoporosis (T-score <=-2.5), fragility fracture, or spinal
cancer, and no bleeding diathesis, severe cardiopulmonary compromise, active infection,
pregnancy, BMI >40, or untreated substance-use disorder. Multidisciplinary screening
including psychological and physical evaluation is documented *** . MRI and conservative-care
documentation are on file.

Plan: Intracept basivertebral nerve ablation — CPT 64628 (first two vertebral bodies) and
64629 (each additional) — at level(s) *** within L3-S1, one-time treatment per vertebral
body and up to 4 bodies in one procedure. Risks, benefits, and alternatives discussed;
consent obtained.