Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain
Treatment: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628)
The insurer denied coverage for thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628)
The denial is overturned

This case involves an adult who was diagnosed with vertebrogenic low back pain. Magnetic resonance imaging (MRI) of the lumbar spine noted degenerative changes with moderate central canal and bilateral lateral recess stenosis at lumbar (L) 4-L5. There was diffuse disc bulging and bilateral facet arthrosis at this level with moderate left-sided and mild right-sided neuroforaminal narrowing. An office visit note indicated the patient had back pain for several years and epidural steroid injections provided no significant relief. Medication included Tylenol. The patient's pain was predominantly axial and worse with flexion. The pain was 6-7/10 in severity. Exam findings noted positive straight leg raise testing with no other significant findings. The physician was recommending Intracept at L4, L5, and sacral (S) 1.  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Current peer-reviewed 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. Literature has also noted that to date, only basivertebral nerve ablation has demonstrated consistent clinical efficacy in the treatment of vertebrogenic low back pain with intraosseous radiofrequency (RF) ablation being studied in Level I randomized controlled trials (RCTs). The most widely used and studied technique (The Intracept Procedure, Relievant Medsystems Inc) has demonstrated consistent, statistically significant, clinically meaningful, and durable improvements in pain and function, as well as an excellent safety profile.  

The thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral has final approval from the appropriate regulatory bodies for this diagnosis.

The information provided for the review stated that the patient was found to have Modic changes on MRI and to have failed to respond to other treatment modalities. The physician recommended the Intracept procedure to address the patient's condition indicating that it is safe and effective with documented evidence of long-term benefit. Given the scientific evidence and peer-reviewed literature, the patient was found to be a suitable candidate for Intracept with scientific evidence confirming improvement in health outcomes. The Intracept procedure has become a mainstream treatment for the patient's condition. 

This patient is a good candidate for thermal destruction of intraosseous basal vertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral.

Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is one of the best available treatments for the patient at this time.

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

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

The carrier's denial of thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628) should be overturned.