Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Facet Arthropathy
Treatment: procedure code 22899, nerve treatment in the spine
The insurer denied coverage for procedure code 22899, nerve treatment in the spine
The denial is upheld

This is a patient with a past medical history includes Bertolotti's syndrome and lumbar facet arthropathy. Prior treatment included spinal injections, a home exercise program (HEP), chiropractic treatment, acupuncture, and medications.  Lumbar spine magnetic resonance imaging (MRI) revealed Modic I endplate changes at lumbar vertebrae (L) 4-5.

According to visit note indicated, "She presented to the Pain Management physician's office to discuss treatment options for chronic lower back pain. The patient recently had an injection of the right L (lumbar) 5 lumbosacral transitional vertebrae. She reported good relief while standing. Pain persisted with sitting and lying down. The pain continues to impact her work and activities of daily living (ADL). The patient has tried and failed conservative treatment for over six months. She had tried a home exercise program (HEP), chiropractic adjustments, acupuncture, and medications. The physician recommended the Intracept procedure to treat back pain."

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome for this patient.

Per Fischgrund, J. S., et al., "Patients treated with RF [radiofrequency] ablation of the BVN [basivertebral nerve] for CLBP[chronic low back pain] exhibited sustained clinical benefits in Owestry disability index (ODI) and VAS [visual analog scale] and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP."

Per Khalil, J. G., et al., "Minimally invasive RF ablation of the BVN led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP [low back pain]."

In sum, there have been multiple studies, including randomized controlled trials, where the proposed treatment has been showed to support improvement in health outcomes.      

This patient is not a good candidate for the procedure code 22899, nerve treatment in the spine.

There is no record of a trial of formal physical therapy directed to the lumbar spine, which would be considered a first-line conservative treatment. Inclusion criteria for studies of intraosseous radiofrequency ablation of the basivertebral nerve include failed trials of conservative care.     

The procedure code 22899, nerve treatment in the spine is not the best available treatment for this patient, at this time.

A trial of formal physical therapy would be the best available treatment at this time.     

There is no evidence to directly compare the efficacy of physical therapy and intraosseous radiofrequency ablation of the basivertebral nerve for the treatment of chronic low back pain. However, physical therapy is a less invasive, and lower risk intervention, and therefore, based on the clinical information, is likely to be more beneficial at this time.

The proposed procedure is invasive, and thus, carries risks of infection and nerve injury that would not be associated with physical therapy.  The requested procedure is not likely to be more beneficial than any standard procedures.                                            

The carrier's denial of the procedure code 22899, nerve treatment in the spine should be upheld.