Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain.

Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

The insurer denied coverage for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

The denial is upheld.

The patient has a history of low back and neck pain. Treatment included physical therapy, chiropractic care, heat, ice, over the counter medications (OTCs), and a transcutaneous electrical nerve stimulation (TENS) unit. She responded well to transforaminal epidural steroid injections. She has a diagnosis of ankylosing spondylitis. She had sacroiliac joint injections and medial branch blocks to the lumbar spine. Her last appointment was a telemedicine visit. No details are provided regarding findings. In a lumbar spine magnetic resonance imaging (MRI) she has a spondylolisthesis at lumbar (L)5 - sacral (S)1 with impingement of the exiting nerve roots bilaterally. There are disc bulges at other levels. It was recommended she undergo the Intracept procedure, which has been denied and is being appealed.

Peer reviewed literature does not support a result of improvement in health outcomes with the requested procedure.      

The requested procedure does have final approval from the appropriate regulatory bodies for this diagnosis. 

Previous treatment measures instituted are directed for the treatment of radiculopathy. The diagnosis would be a contraindication to these treatment measures. Therefore, this patient is not a good candidate for the requested procedure.     

The determination of the pain generator is very complicated for this patient and does not appear to be related to the vertebral body. Therefore, the requested procedure is not the best available treatment for this patient at this time.

The adverse risks are increased over standard treatment/services.

"Intraosseous ablation of the BVN is a relatively new minimally invasive treatment for the relief of chronic lower back pain (CLBP) that is diagnosed using well-established clinical and MRI findings. The procedure is supported by level 1 evidence including 2 randomized controlled trials (RCTs) 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." Industry funding is a potential source of study bias for the available data reviewed. There are a limited number of studies and follow up has been short-term for the majority of studied patients. The effect on the primary degenerative process is unknown. (Lorio, M. et al. 2020)   

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk is substantially increased over standard treatments.

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral should be upheld.