Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cervical spondylosis

Treatment: procedure code 64628 thermal destruction of intraosseous Basi vertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral

The insurer denied coverage for procedure code 64628 thermal destruction of intraosseous Basi vertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral

The denial is overturned

This case involves an adult male who is being recommended for treatment using the Intracept procedure due to chronic pain. Records noted that the patient had a primary problem with chronic low back pain due to degenerative disc disease that resulted in the development of vertebral genic pain identified by Modic type changes on the MRI (magnetic resonance imaging). The physician stated that the moderate changes can also be described as endplate changes associated with inflammation, edema, disruption, and/or fissuring, fibrovascular bone marrow changes, or fatty bone marrow changes. The physician was recommending the Intracept procedure given that Modic changes identify appropriate patients for basivertebral nerve ablation with approximate 93% specificity. The physician noted that the Intracept procedure received initial FDA (Food and Drug Administration) clearance in 2016. With clearance, the indications for use were defined as patients who have had pain for greater than 6 months, failed treatment for greater than 6 months, and have MRI evidence of moderate changes at L (lumbar) 3-S (sacral) 1 vertebral bodies. The physician confirmed that the patient's history of low back pain began over 6 months prior, with failure of multiple treatments to include chiropractic care, home exercises, massage therapy, medial branch block injections, medication management, physical therapy, and trigger point injections.  He was on ibuprofen and tizanidine and endorsed that his pain had a significant impact on his activities of daily living with nothing providing substantial relief. An MRI report demonstrated degenerative endplate changes at L5-S1 displaces. The physician stated that long-term use of NSAIDs (non-steroidal anti-inflammatories) and opioids were not ideal given the current opioid substance abuse problem, and effects that these medications can have on the stomach, liver, and kidneys. The patient previously received a notice of adverse determination regarding thermal destruction of interosseous basivertebral nerves given that this is not considered a covered service with medical studies considered incomplete. This review pertains to the denial of coverage for procedure code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Procedure code 64628 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.

This patient is a good candidate for procedure code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral.

Procedure code 64628 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 this patient at this time.

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

Current medical literature has noted that vertebral endplates, innervated by the basivertebral nerve, can be a source of vertebral genic low back pain when damaged with inflammation, visible as x1 or 2 Modic type changes. Interosseous vertebral nerve ablation demonstrates an excellent safety profile and significant improvements in pain, function, and quality of life that are sustained in patients with chronic vertebral genic low back pain. While the current policy claimed that the proposed treatment has not been shown to be effective in treating the patient's condition, medical literature has confirmed that this treatment modality has been in effect since 2016 with approval from the Food and Drug Administration and has proven to be an effective method in treating chronic low back pain caused by moderate changes verified by MRI, and in those patients who have tried and failed other treatment measures.

The requested service is likely to be at least as beneficial as other standard treatments/procedures for this patient.

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