Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic pain

Treatment: service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied coverage for service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is overturned.

This is a female patient diagnosed with spinal stenosis of lumbar region without neurogenic claudication; lumbar facet arthropathy; and long-term prescription opiate use. Magnetic Resonance Imaging (MRI) of the lumbar spine revealed degenerative changes in the lumbar spine described most severe at L4-5 where there was grade 1 anterolisthesis with uncovering of the disc and bilateral facet hypertrophy resulting in mild right greater than left neuroforaminal narrowing and mild to moderate canal stenosis. Partially visualized fluid collection in the left subcutaneous soft tissues of the back at the L1 level was seen. On a telemedicine evaluation, the patient complained of back and leg pain. There was decreased range of motion with pain in the back. There was pain with range of motion of the bilateral knees. The patient was recommended for an Intracept procedure.

Scientific literature supports that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in ODI [Oswestry disability index] and VAS [visual analog score] 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 basivertebral nerve 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.

In this case, the patient complained of back and leg pain. The MRI revealed grade 1 anterolisthesis at L4-5 with uncovering of the disc and bilateral facet hypertrophy resulting in mild neuroforaminal narrowing as well as mild to moderate canal stenosis.  There was also grade 1 retrolisthesis at L5-S1 with uncovering of the disc and left facet hypertrophy resulting in mild to moderate left neuroforaminal narrowing. In an addendum it was noted the MRI did demonstrate Modic type degenerative endplate changes at L4-5 and L5-S1. The patient has been treated with physical therapy, heat/ice, and medications. 

The request is for the Intracept procedure at L4, L5, and S1. This is a relatively new procedure, but it does have Level 1 evidence of effectiveness. The patient has documented failure of other more conservative treatment. This procedure is likely to be more beneficial than any other standard treatment.

The carrier's denial of service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) should be overturned.