Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation

The insurer denied coverage for procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation

The denial is upheld

The patient has a history of lower back pain. The patient presented to the pain management physician's office for a follow up for lower back pain. The magnetic resonance imaging (MRI) revealed Modic changes at lumbar (L)4, L5, and sacral (S)1. The physician recommended the Intracept procedure to treat lower back pain. 

The insurer has denied coverage for procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

LIMITATIONS

(1) Industry funding is a potential source of study bias for the available data reviewed.
(2) Limited number of studies.
(3) Short-term follow up for the majority of studied patients.
(4) Unknown effect on the primary degenerative process." (Lorio, M. et al. 2020).

"Conservative management often includes over-the-counter pain medications such as acetaminophen or non steroidal anti inflammatory drugs (NSAIDs). Muscle relaxers, gabapentin, topical analgesics, and opioids all play a role in the management of back pain, on a case-by-case basis. Most cases of back pain are mechanical in origin and respond to activity modification, rest, ice, and heat. Physical therapy and core strengthening exercises also play a role...

According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year. However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, spinal fusion, or lumbar disk replacement." (Casiano, V. E. et al. 2021).

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings." (Conger, A. et al. 2021).

Medicare does not have a National Coverage Determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. 

Procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation does not have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation. Intracept remains a procedure without established efficacy. 

Procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation is not the best available treatment for this patient at this time. 

The adverse risks are increased over standard treatment/services. There are risks associated with the procedure which are increased over standard treatment/services. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

In summary, the denial of procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation 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 substantially increased over standard treatments.