Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: nerve ablation procedure (procedure code 64628)
The insurer denied coverage for nerve ablation procedure (procedure code 64628).
The denial is upheld.

This case involves a patient with a history of chronic back pain. Magnetic resonance imaging (MRI) of the lumbar spine noted Modic type I endplate signal changes at lumbar (L) 4-5. It was also noted there was Modic type II endplate signal changes at L5- sacral (S) 1. The patient was seen with complaints of low back pain and left thigh numbness. Diagnoses included vertebrogenic low back pain. Past treatment included lumbar radiofrequency ablation (RFA), physical therapy (PT), medication management and Intracept procedure previously at L5-S1. The patient underwent an epidural steroid injection (ESI). Follow-up reported the patient had 50% reduction in pain for 4 weeks. Treatment plan included medication management, PT, and ESI. The patient underwent an interlaminar ESI. Appeal letter reported the patient had chronic low back pain (CLBP) with Modic changes. The patient was noted to have endplate changes at L3-4 and vertebrogenic pain. The patient underwent radiofrequency ablation (RFA) on the left at L3-S1.

Scientific literature supports RFA of the basivertebral nerve (BVN) for CLBP exhibited sustained clinical benefits in Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) and maintained high responder rates at 2 years following treatment. Per the International Society for the Advancement of Spine Surgery guideline, intraosseous ablation of the BVN from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain of at least 6 months duration when there is failure to respond to at least 6 months of nonsurgical management, and MRI demonstrated Modic change 1 or Modic change 2 in at least 1 vertebral endplate at 1 or more levels from L3 to S1.

The Intracept procedure does have final approval from the appropriate regulatory bodies for the diagnosis.  The adverse risk is not increased over standard treatment/services.  However, the patient would not be a good candidate for this procedure, and it would not be the best available treatment at this time. In this case, the patient is noted to have chronic back pain despite conservative measures. The provider reported there were endplate changes at L3 and L4 on imaging. However, the MRI did not note Modic type I or II changes at L3-4. There were changes at L4-5, but this is not the requested level. There is a lack of imaging evidence to support the proposed procedure at this time. 

Peer reviewed literature does not support a result of improvement in health outcomes with the requested procedure. The requested procedure does have final regulatory approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for the requested procedure. It is not the best available treatment for this patient at this time.

The denial of the nerve ablation procedure (procedure code 64628) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.