Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: 64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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 all 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 years ago. The patient has had multiple treatments including chiropractic care, facet injections, lumbar epidural steroid injections, medial branch block injections, medication management (Ibuprofen), and sacroiliac joint injections. The pain has had a significant impact on activities of daily living (ADLs) and nothing has provided significant sustainable relief. The patient had a magnetic resonance imaging (MRI) performed and the MRI demonstrated Modic changes. The treating provider has requested therapy with 64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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 outcomes.

64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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 does not have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for 64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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.

Since this procedure does not have established clinical efficacy, the patient is not a good candidate for 64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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.     

64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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 the best available treatment for this patient at this time. 

In summary, the denial of 64628 - Thermal destruction of intraosseous basivertebral nerve, including all 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 service/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 risks are substantially increased over standard treatments.