Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: intraosseous basivertebral nerve ablation, current procedural terminology (CPT) codes 64628 and 64629
The insurer denied coverage for intraosseous basivertebral nerve ablation, current procedural terminology (CPT) codes 64628 and 64629
The denial is upheld.

This is an adult with a history of chronic back pain and chronic neck pain. The patient presented to the Pain Management physician's office for a follow up for back pain. Imaging of the spine revealed multilevel degenerative disc disease. The patient tried and failed multiple injections, medications, and a home exercise program. The treating practitioner recommended the Intracept procedure. 

The Intracept procedure is "intraosseous ablation of the basivertebral nerve." It has been proposed to address low back pain identified by Modic changes. 

The procedure is performed within the vertebral body. It has been proposed that patients manifest pain relief and no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons nor spine surgeons. There are no National Organizations which provide guideline nor indication. The International Society for the Advancement of Spine Surgery (ISASS) reported "it may be beneficial."

A search was performed using PubMed. The key word was Intracept Lumbar. There were several references. There was a reported 65% success rate and further high-quality studies were recommended. The coverage statement by ISASS was. "Basivertebral Nerve Ablation (BVNA) may provide a treatment option to fill the treatment gap paradigm for patients that fail nonsurgical treatment."

The findings were this procedure is currently Investigational/Experimental. There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely IRB (Investigational Review Board). The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body.

There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer.

It is important to define the pain generator and exclude other sites of pathology which could be causative. The records show degenerative disc disease (intervertebral disc and not the basivertebral nerve), facet pathology, nerve compression and stenosis. Any one of these or in combination could be responsible for symptoms. A relative contraindication is a treatable surgical lesion. The treating physician reports the Modic changes to several levels but does not report nor discuss the probable etiology of pain (disc, facet, stenosis, nerve compression). 

The likelihood of the basivertebral nerve being the pain generator is not credible. 

In summary, the denial of intraosseous basivertebral nerve ablation, current procedural terminology (CPT) codes 64628 and 64629 and coverage for the requested 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 risk are substantially increased over standard treatments.