Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: intraosseous basivertebral nerve ablation (procedure codes 64628 and 64629)

The insurer denied coverage for intraosseous basivertebral nerve ablation (procedure codes 64628 and 64629) 

The denial is upheld

This is the case of an adult with a history of lumbar disc degeneration, lumbar disc displacement, and vertebrogenic low back pain. The patient was seen by a pain medicine specialist for a follow-up visit after transforaminal epidural steroid injection (TFESI). The patient reported a residual burning sensation to the low back, and increased pain with forward flexion and prolonged sitting. The duration was 6 months. 

The patient's physical exam revealed diminished range of motion (ROM) in all planes and pain with flexion and extension. 

 A magnetic resonance imaging (MRI) was completed and showed multilevel degenerative changes with spinal canal stenosis and mass effect on descending nerve roots and compression of descending S (sacral) 1 nerves in lateral recesses bilaterally.

The physician recommended the Intracept procedure. He also recommended additional epidural steroid injections (ESI). 

It is unclear whether intraosseous basivertebral nerve ablation (procedure codes 64628 and 64629) is considered more beneficial for this patient's diagnosis. There are several studies; however, no conclusions can be made. No definite statement nor guidelines showing definitive efficacy have been reported. The Food and Drug Administration (FDA) approval had been granted for Pre Market approval. The FDA does not provide statements regarding benefit.

This patient is not a good candidate for intraosseous basivertebral nerve ablation (procedure code 64628). No defined pain generator is present. The records show chronic back pain with several sites of pathology. Injections and multiple conservative treatments have been completed for facet disease, disc disease, stenosis and herniations. There is evidence of nerve compression to several levels. The report of axial pain vs radicular pain is inconsistent. The likelihood of the basivertebral nerve (BVN) causing the back pain is not credible. The physician is also requesting additional ESI. 

Intraosseous basivertebral nerve ablation (procedure code 64628) is not the best available treatment for this patient at this time. 

The procedure is invasive. There have been reported complications of infection, broken hardware and retroperitoneal hematoma.


The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

In summary, the denial of  intraosseous basivertebral nerve ablation (procedure codes 64628 and 64629) and coverage for the requested service 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.