Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain (CLBP)
Treatment: procedure code 64628 (Intracept procedure; intraosseous basivertebral nerve ablation)
The insurer denied coverage for procedure code 64628 (Intracept procedure; intraosseous basivertebral nerve ablation)
The denial is upheld

The patient is an adult with a medical diagnosis of chronic low back pain (CLBP). The treating provider is requesting plan approval for treatment with code 64628, Intracept procedure, intraosseous basivertebral nerve ablation.  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

"Intraosseous ablation of the BVN (basiveterbral nerve) is a relatively new minimally invasive treatment for the relief of CLBP that is diagnosed using well-established clinical and MRI (magnetic resonance imaging) findings. The procedure is supported by level 1 evidence including 2 RCTs (randomized controlled trials) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies. These results were seen in a patient population that is one of the most expensive and difficult to provide care for, and in this era of rising health care costs and increasing need for therapies to reduce the use of opioids, BVN ablation may provide a treatment option to fill the gap in the treatment paradigm for patients that fail nonsurgical treatment. (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, et al., 2020).

"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 BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings" (Conger, A. et al. 2021).

This patient is a good candidate for procedure code 64628, Intracept procedure; intraosseous basivertebral nerve ablation. 

However, procedure code 64628, Intracept procedure, 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. This is an advanced interventional procedure that requires entering the vertebral body, which carries increased risks. There are standard procedures that would address the patient's symptoms better than this, such as epidurals or even a spinal cord stimulator. 

In summary, the denial of procedure code 64628 (Intracept procedure; intraosseous basivertebral nerve ablation) and coverage for the requested service/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 may be increased over standard treatments.