Understanding Insurance Coverage and Next Steps
Living with chronic low back pain is challenging enough—navigating insurance shouldn’t add more stress. This page will help you understand what to expect with Medicare, Medicaid, commercial insurance, and self-pay options for the Intracept Procedure.
What to Know First
- The Intracept Procedure is covered by many major insurance plans, including Medicare, and coverage is continuing to expand.
- Every insurance plan has its own guidelines, and coverage varies from one plan to another.
- Even if your insurance plan does not currently offer coverage for Intracept, it is still possible to obtain approval through appeals and external reviews.
- Prior authorization is a common term used to receive your insurance company’s approval before the procedure and is typically required.
- Some doctor offices partner with the Boston Scientific Patient Access & Reimbursement team to help guide you through the process, if you have signed a consent form.
Understanding the Insurance Process for Intracept
While every patient’s journey is unique, most follow a similar path when navigating insurance for the Intracept Procedure:
Select your insurance plan to receive more information about coverage for the Intracept Procedure.
Medicare Coverage
If you have a red, white, and blue Medicare card, you’re covered by Medicare. Your coverage may come from traditional Medicare, which is managed by the federal government, or from a Medicare Advantage plan, which is offered through a private insurance company approved by Medicare.
Traditional Medicare
If you have traditional Medicare, good news - Medicare covers the Intracept Procedure when deemed appropriate by a healthcare provider and certain criteria are met.
To qualify, Medicare typically requires:
- Chronic low back pain lasting 6 months or more
- MRI evidence of Modic changes (a marker of vertebrogenic pain) on one or more vertebral levels L3-S1
- Proof that non-surgical treatments (like physical therapy, medications, or injections) haven’t helped
Your doctor will handle the documentation, but your Medicare Administrative Contractor (MAC) makes the final determination.
Medicare Advantage Plans
Medicare Advantage plans provide the same coverage as original Medicare, but they are managed by private insurers. These plans often require prior authorization or pre-determination before a procedure can be performed, helping confirm coverage and estimate potential out-of-pocket costs.
While Medicare Advantage plans are supposed to offer the same coverage as original Medicare, they may have extra requirements or restrictions, such as prior authorization or network limitations.
💡Tip: Always check the details of your Medicare Advantage plan and discuss them with your doctor’s office to understand any additional documentation or approval steps required before scheduling the Intracept Procedure.
Commercial Insurance
More and more commercial insurers - including Anthem and Humana - now cover the Intracept Procedure.
Each plan may have unique requirements, but most will ask for:
- MRI proof of Modic changes
- Suffered with chronic low back pain for at least 6 months
- Records showing you’ve tried and not improved with conservative treatments
- A prior authorization request before scheduling
Some plans have a negative coverage policy for Intracept which means they deem the procedure “experimental or investigational”. This is common language for devices and procedures new to the market and it takes time for the insurance companies to adopt coverage. This does not mean that it's not FDA approved, nor does it mean your doctor is “experimenting” on you. Even if your plan has a negative coverage policy and/or initially denies coverage, your doctor and the Boston Scientific patient access and reimbursement team can help with appeals and additional documentation. Through the appeals process, even plans with a negative coverage policy may approve your case based on it being medically necessary for you.
💡Tip: Contact your insurance company’s member services line and ask specifically whether CPT 64628 or 64629 (Basivertebral Nerve Ablation) is covered. Provide this code to get the most accurate answer. If they tell you it's not covered, work with your doctor or Boston Scientific’s Patient Access Team to develop a plan to seek coverage for your case specifically.
Paying Out of Pocket
If your insurance doesn’t yet cover the Intracept Procedure or you’ve been denied you still have options. Before choosing to pay out of pocket for the procedure, you may wish to consider the following:
- If you have received a denial from your insurance company you can advocate for yourself by exploring appeal options or asking your doctor to resubmit your prior-authorization request with additional clinical documentation that supports medical necessity for the procedure
- Ask your provider for a cost estimate that includes doctor, facility, and anesthesia fees
- Some clinics may offer self-pay discounts, payment plans, or financing options
- Some doctor offices work with the Boston Scientific Patient Access & Reimbursement team to partner with you during this process, after receiving your signed consent
Don’t give up if your plan doesn’t cover Intracept yet — coverage is expanding, and your doctor’s office can help advocate on your behalf. Many times, insurance companies give case by case approvals based on medical necessity.
💡Tip: When comparing self-pay options, ask whether your provider offers a bundled price (covering all facility and physician costs). This can make the process more predictable and may qualify you for flexible payment terms.
Medicaid Coverage
Coverage under Medicaid varies by state. Some state Medicaid programs cover the Intracept Procedure, while others are still reviewing it.
Your doctor’s office can contact your state Medicaid office or managed Medicaid plan to check for current coverage.
Even if your state doesn’t yet cover the procedure, prior authorization requests and appeals can sometimes help secure approval.
Boston Scientific’s team can provide documentation and support materials to assist you and your doctor to help seek coverage.
💡Tip: Ask your provider to submit a coverage inquiry or prior authorization to your Medicaid plan - even if Intracept isn’t yet listed as a covered benefit. Medicaid coverage policies change frequently, and new approvals are added regularly.
We’re Here to Help
Boston Scientific has a dedicated Patient Access and Reimbursement Support Team that works with your doctor’s office to:
- Help with prior authorization
- Provide appeal support if coverage is denied
Your doctor can connect you with this team upon request.
💡Tip: If you’re waiting for insurance approval, stay in contact with your provider’s prior-authorization specialist. Checking in weekly can help avoid delays and ensure paperwork moves forward quickly.