Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

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

The denial is upheld.

Reviewer #3:

This is a patient with a history of low back pain beginning over two years ago. The patient has had multiple treatments including chiropractic care, heat/ice, medial branch block injections, physical therapy, sacroiliac joint injections, transcutaneous electrical nerve stimulation (TENs) unit, and transforaminal epidural steroid injections. The patient is on the current medications Advil and Aleve, but nothing has provided significant sustainable relief.  The patient had a Magnetic Resonance Imaging (MRI) performed which demonstrated Modic changes. The treating provider has requested therapy with 64628 Thermal destruction of intraosseous basivertebral nerve, including imaging guidance; first 2 vertebral bodies, lumbar or sacral. 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral, which is under review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

At this time Intracept remains a procedure without established efficacy. While results may appear promising additional studies are necessary to determine efficacy as compared to other conventional therapies. Medicare does not have a national coverage determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. 

Therefore, the request for 64628 Thermal destruction of intraosseous basivertebral nerve, including imaging guidance; first 2 vertebral bodies, lumbar or sacral. 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral is not medically necessary and is denied.

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings" (Conger, A., et al. 2021).

In conclusion, the Intracept remains a procedure without established efficacy.

Due to a lack of long-term comparative data on the efficacy and safety of percutaneous vertebral and vertebral endplate procedures, there is no evidence the requested service would likely be more beneficial than any of the standard treatments/procedures for this patient. As such, the denial is upheld.                                                    

In summary, the denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including imaging guidance; first 2 vertebral bodies, lumbar or sacral. 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 upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition.