CPT 64628 · Intradiscal · Tricare
Intracept — Basivertebral Nerve Ablation (1st level) at Tricare.
How Tricare approaches CPT 64628 (Intracept — Basivertebral Nerve Ablation (1st level)) for prior-authorization review: at last review on 2026-03-17, the policy covers this code with prior authorization required.
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TPM 6010.60-M Change 48Verification pending. This record is awaiting confirmation against the latest policy document — criteria summary may not reflect the current revision.
Criteria summary
High-level themes from the Tricare 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.
See the full Tricare criteria.
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