Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance
The insurer denied the Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance.
The denial is upheld.

The patient is a male.  The patient was recommended for destruction of intraosseous basivertebral nerve of the vertebral body.  The patient had an MRI (magnetic resonance imaging) of the lumbar spine showing Modic type 1 and type 2 degenerative endplate changes at L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra) level.  There is disc desiccation and narrowing at this level.  There is fluid within several facet joints within the lower lumbar region, which may be degenerative nature.  The patient was evaluated with chronic low back pain.  The physical exam shows mild tenderness on lumbosacral percussion.

The procedure was denied by the health plan upon review, as they consider it to be experimental/investigational and unproven.  The denial was subsequently appealed.  The doctor provided scientific literature showing evidence of efficacy with long-term studies.  The doctor indicated that this procedure has been present and available for many years and has been shown to be effective for patients with low back pain.

This is a review for the treatment with the ablation of the basivertebral nerves for low back pain.

No, the health plan should not cover the requested health service.

There is limited scientific evidence showing efficacy of this procedure for treatment of low back pain.  The current prospective studies are corporate-sponsored, with one study showing longer-term benefit of the procedure.  This first report had 5 year data of 114 patients.  The second prospective study provides short-term evidence of efficacy.  This is also corporate-sponsored.

The prospective randomized study by Khalil, et al evaluated 140 patients.  At three months follow-up, 74% of patients that received RF (radiofrequency) ablation achieved a greater than 10 point improvement in ODI (Oswestry Disability Index) compared with 32.7% in the standard arm.  The one-year study by the same group indicated persistent improvement in ODI (Oswestry Disability Index) in the ablation group.

There is one five year study of 117 patients by Fischgrund, et al. In this report, 66% of patients reported a greater than 50% reduction in pain.  There was a 2 point change in VAS (Visual Analogue Scale) in 75% of patients at five years.

Given the minimal current scientific literature, there is no clear evidence that this treatment provides improved long-term outcomes in patients.  The literature shows some benefit in the long-term, but overall this would not be sufficient to indicate that this procedure would be standard of care.  It is considered investigational/experimental and unproven at this time.  Therefore, it should not be covered by the health plan.

The evidence does not clearly show that there is superior benefit to the use of this procedure over standard treatment options for back pain complaints due to degenerative disc disease.  Further studies would be necessary to determine the efficacy over standard treatments, such as aggressive exercise program and medications.