Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Chronic Low Back Pain.

Treatment: Surgical procedure to treat low back pain (procedure code 64628 and 64629).

The insurer denied coverage for surgical procedure to treat low back pain (procedure code 64628 and 64629).

The denial is upheld. 



This case involves a patient with a subject for review for the denial of coverage for a surgical procedure to treat low back pain (procedure code 64628 and 64629).

The patient had an magnetic resonance imaging (MRI) of the lumbar spine, and it revealed moderate multilevel lower thoracic and lumbar degenerative disc disease with a secondary mild degenerative levoscoliosis, right foraminal disc herniation at L (lumbar) 2-3 with mild compression of the right L2 nerve root, left lateral recess disc herniation at L5-S (sacral) 1 compressing the left S1 nerve root, and small bulges at L1-2 and L4-5 without stenosis or nerve root compression. 

The patient was seen for a follow-up pain management visit for their low back pain. In the past year, the patient underwent bariatric surgery, overall, the patient lost 100 pounds (lbs) and is doing well. However, losing weight did not improve their back pain. The patient is currently active in physical therapy (PT) for back, knee, and hip pain. 

In this case, this is a patient who has an axial lumbar pain that has not responded to 3 months of conservative therapy including physical therapy or non-steroidal anti-inflammatory drugs (NSAID) therapy. The pain is interfering with activities of daily living (ADLs) and functional ability. There is no radicular pain noted and he is positive for Kemps maneuver. The patient's lower back pain was reported that it is worse with extension, flexion, prolonged sitting, and prolonged standing. The patient also complains of mid back pain, and right groin pain. 

MRI of the lumbar spine revealed a small bulge without stenosis or nerve root compression on L1-2, right foraminal disc herniation with mild compression of the right L2 nerve root at L2-3, small bulge without stenosis or nerve root compression at L4-5, and a left lateral recess disc herniation compressing the left S1 nerve root at L5-S1. MRI thoracic spine also revealed a mild multilevel thoracic degenerative disc disease, small disc herniations at T (thoracic) 8-9, T10-11, and T11-12 without spinal cord or nerve root compression and a chronic anterior wedge compression fracture of T9 with approximate 30% (percent) loss of height. 

According to the Food and Drug Administration (FDA), basivertebral nerve ablation have demonstrated consistent, reproducible, clinically meaningful, statistically significant improvement in reducing pain and improving functioning in patients with diagnostic evidence of vertebral pain for patients who has not responded to at least six months of conservative care and is also accompanied by either Type I or Type II Modic Changes on MRI. For this patient, he is not a good candidate for the surgical procedure to treat low back pain (procedure code 64628 and 64629) due to the patient only having 3 months of conservative management and the imaging that was submitted was more than a year ago and did not specify Modic Changes. Based on the medical records submitted, the requested service is not proven beneficial for the patient. 

In summary, the denial of a surgical procedure to treat low back pain (procedure code 64628 and 64629) 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 risk are not substantially increased over standard treatments.