Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3

Diagnosis: Low 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 and 64629 

The denial is upheld

This adult patient has history of vertebral genic pain identified by Modic changes who was being recommended for the Intracept procedure. The patient's chief complaint included lower back pain with buttock and bilateral foot pain. Prior relevant treatment included facet blocks, medications, diagnostic imaging, facet rhizotomies, and epidural steroid injections. Records noted the patient was also being treated with a spinal cord stimulator (SCS), which provided some relief of pain. Magnetic resonance imaging (MRI) noted interval worsening of multilevel degenerative changes of the lumbar spine with severe spinal stenosis at lumbar (L)3-L4 with possible cauda equina compression. The physician was recommending Intracept procedure at L3, L4, L5, and sacral (S) 1 under general anesthesia with plans to turn off the SCS during the procedure.  

Current medical literature has noted that low back pain is one of the most prevalent musculoskeletal ailments in the United States. Intraosseous radiofrequency ablation of the basivertebral nerve is an effective and durable therapy for low back pain and can be offered to patients who have chronic low back pain of greater than 6 months of duration, failure to respond to noninvasive therapies for 6 months, with either Modic Type I or Type II changes at L3-S1. The records provided for the review noted that the patient had a history of low back pain and failed to respond to multiple conservative treatment measures and remained symptomatic. However, the treating physician was planning to obtain an updated MRI of the lumbar spine given that the prior MRI was a few years old. The prior MRI noted Modic endplate changes type I at L2-L3 and to a lesser degree at L5-S1. Additionally, the physician was requesting the Intracept procedure at L2-S1 with no Modic changes noted at the L4 level. Therefore, while medical literature has shown that the Intracept procedure may be appropriate for treating the patient's condition at L2-L3 and L5-S1, with scientific evidence from peer-reviewed literature supporting improvement in health outcomes and confirmation that Intracept has received final approval from appropriate regulatory bodies for this diagnosis, the patient is not a good candidate for the procedure given findings.  

The proposed treatment is considered one of the best available treatments for a patient with Modic changes unresponsive to at least 6 months of treatment, with the adverse risks not increased over standard treatment/services currently marketed for treatment.  The available MRI cannot be used to support the requested procedure given changes that may have occurred in the interval. 

Peer reviewed literature does not support a result of improvement in health outcomes. The requested procedure does have final regulatory approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for the requested procedure.  It is not the best available treatment for this patient at this time.

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.

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