Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 

Treatment: (procedure code 64628) thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 
The insurer denied coverage for (procedure code 64628) thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 

The denial is overturned. 

This case involves a female with a history of chronic low back pain who was being recommended for thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, for 2 vertebral bodies, lumbar or sacral with claims that she began having back pain 5 years prior and received multiple treatments to include lumbar epidural steroid injections, medication management, microdiscectomy, physical therapy, and radiofrequency ablations. The patient continued to have chronic neck and back pain described as aching and with radiation to the posterior aspect of the right thigh. The physician stated that the patient had two bulging disks in the low back and planned to treat the nerve inside the bones called basivertebral nerves. The patient received a notice of adverse determination regarding the requested services as a treatment was considered investigational in all cases. An appeal was submitted reiterating the patient's long-term history of low back pain and treatment measures that failed to resolve her symptoms. This review pertains to the denial of coverage for procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 

The Intracept Procedure is based upon 20 years of scientific research on endplates and the basivertebral nerve (BVN). The procedure targets the BVN while preserving the structures of the spine and without the use of an implant. The radiofrequency ablation of the BVN for the relief of chronic low back pain represents a new treatment modality and is distinct from other radiofrequency ablation therapies used in the spine such as facet ablation. BVN ablation is technically, scientifically distinct and that it uses a transpedicular approach into the vertebral body to access the BVN directly to alleviate it vertebra genic pain, and furthermore it mandates strict patient selection criteria. There is adequate body of literature and studies to support the Intracept procedure including two level 1 class studies (both were randomized control studies--the highest level of clinical research) which show superiority. Further, there is level 1 data extending to 5 years of efficacy. 

Also, the device is FDA (food and drug administration) approved since 2016 and major medical societies support it application. Given the current literature, scientific evidence supports results of improvement in health outcome. The treatment has been approved by the Food and Drug Administration for the treatment of chronic low back pain. Based upon the provided evidence, the patient was considered a good candidate for the proposed treatment given that she has failed multiple treatment methods, both operative and nonoperative and remains symptomatic. The adverse risks are similar to that of traditional ablation. 

Given that this is a minimally invasive treatment, which targets a nerve within the vertebral bones that has been found to be the cause of low back pain conditions, it was determined that the service is likely to be the same or more beneficial to standard treatments or procedures for this patient. 

The carrier's denial of procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral should be overturned.