Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.
The insurer denied coverage for the 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.
The denial is overturned.

This case involves a patient diagnosed with lower back pain, arthritis, degenerative disc disease, lumbar radiculopathy, and lumbar stenosis who was being recommended for the Intracept procedure. An MRI (magnetic resonance imaging) of the lumbar spine noted multilevel degenerative disc disease with spinal canal stenosis and neuroforaminal narrowing. The patient reported 8/10 lower back pain with radiation to the right hip and groin and extending to the anterior right thigh. The patient was using Lyrica and Percocet for pain relief and previously received several injections to include bilateral medial branch nerve blocks and epidural steroid injections at multiple levels. The patient is unable to take NSAIDs (non-steroidal anti-inflammatory drugs) due to papillary necrosis. She had positive paraspinal muscle tenderness on the right with normal range of motion and normal strength in the lower extremities.  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

The 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be as beneficial or more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of 64628 Thermal destruction of Intraosseous Basivertebral Nerve, including all imaging guidance, first 2 Vertebral bodies, Lumbar or Sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral, and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition, and the adverse risks are not substantially increased over standard treatments.