CPT 64628 · Intradiscal · Horizon NJ Health — NJ Medicaid
Intracept — Basivertebral Nerve Ablation (1st level) at Horizon NJ Health — NJ Medicaid.
How Horizon NJ Health — NJ Medicaid approaches CPT 64628 (Intracept — Basivertebral Nerve Ablation (1st level)) for prior-authorization review: at last review on 2026-05-06, the policy does not cover this code with prior authorization required.
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Criteria summary
High-level themes from the Horizon NJ Health — NJ Medicaid policy of record for CPT 64628. Verbatim policy text and per-criterion analysis are available after sign-in.
- At least 26 weeks of conservative care typically required.
- Imaging concordance documentation required.
Source: Horizon BCBSNJ — Medical Policy Manual (BVN policy not located)
See the full Horizon NJ Health — NJ Medicaid criteria.
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