Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.

Treatment: Surgical procedure to treat low back pain (Procedure Code 64628).

The insurer denied coverage for surgical procedures to treat low back pain (Procedure Code 64628).

The denial is overturned.



This case involves a patient regarding the Intracept procedure.  The patient was seen for a follow-up visit.  The patient complained of low back pain and was last seen approximately 10 months prior.  The patient described their pain as constant, stabbing discomfort that worsened with flexion and prolonged sitting/activity.  The patient's pain radiated down the right lateral hip to the right buttock with complaints of left lateral hip pain.  Prior relevant treatment included ice/heat, a transcutaneous electrical nerve stimulation (TENS) unit, and acupuncture/chiropractic care with minimal or temporary relief.  The patient continued to engage in home exercises and stretching regimens and previously tried Tylenol and non-steroidal anti-inflammatory drugs (NSAIDs) with minimal relief.  The patient's pain level ranged between 5-7/10.  The magnetic resonance imaging (MRI) report noted shallow broad-based posterior disc herniation at lumbar (L)3-L4 with no central spinal canal stenosis, bilateral facet arthrosis, and mild narrowing of the bilateral neural foramina.  At L4-L5, there was broad-based posterior disc herniation extending 7 millimeters (mm) into the central spinal canal with mild narrowing of the central spinal canal measuring 10 mm.  There is moderate bilateral facet arthrosis and thickening of the ligamentum flavum along with moderate narrowing of the bilateral neural foramina.  The patient had disc height loss and broad-based posterior disc herniation at L5-S1 extending 4 mm into the central spinal canal.  There was no central spinal canal stenosis and facet joints were unremarkable.  The patient had moderate narrowing of the bilateral neural foramina with lumbar spondylosis noted at L3-L4 through L5- sacral (S)1 without critical central spinal canal or neuroforaminal stenosis.  The patient had disc herniations at L4-L5 and L5-S1 with mild narrowing of the central spinal canal at L4-5 and moderate narrowing of the bilateral neural foramina at L4-L5 and L5-S1.  

The treatment is not approvable under the plan's clinical criteria because there is no proof or not enough proof that it improves health.  For that reason, the request was denied.  The patient endorsed that they have suffered from low back pain for 15 years and received multiple injections, physical therapy, acupuncture, and chiropractic care.  The patient experienced only minimal relief despite the cost of treatment.  The appeal letter noted that the vertebral body/body to be treated were L4, L5, and S1.  The report stated the patient failed conservative nonoperative treatment and meets the medical necessity and reasonableness criterion.  The report noted that the Intracept procedure has been Food and Drug Administration (FDA) cleared since 2016 demonstrating the procedure is safe and effective.  Since then, peer-reviewed literature has expanded to where there are more than 30 publications and medical societies supporting the procedure.  The report stated that the patient's chronic low back pain is due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplate changes (motor) on magnetic resonance imaging (MRI).  

In summary, the denial of surgical procedures to treat low back pain (Procedure Code 64628) and coverage for the requested treatment should be reversed. This treatment is 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.