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 and coverage for the requested treatment.

The insurer denied coverage for 64628 Thermal destruction of Intraosseous Basivertebral Nerve, including all Imaging Guidance, first 2 Vertebral bodies, Lumbar or Sacral and coverage for the requested treatment.  The denial is upheld.

Reviewer #3:

In assessing whether intraosseous basivertebral nerve ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Furthermore, despite Food and Drug Administration (FDA) approval, there are many exclusion criteria.

For individuals who have vertebrogenic low back pain and who receive ablation of basivertebral nerves, the evidence includes two randomized controlled trials (RCTs) (SMART and INTRACEPT trials, both sponsored by device manufacturer Relievant Medsystems, Inc.). Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% of patients crossed over to the active treatment group, and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up.

Basivertebral nerve (BVN) ablation using the Intracept procedure is FDA approved in a very select group of patients who have:  1) A history of chronic low back pain (cLBP) of at least 6 months duration; and 2) Failed to respond to at least 6 months of non-surgical management; and 3) Magnetic resonance imaging (MRI) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L (lumbar) 3 to S (sacral) 1; and 4)  Activities of daily living that are limited by persistent low back pain; AND  5) All other reasonable sources of pain have been ruled out.

This patient is not a good candidate for intraosseous basivertebral nerve ablation. There are other evidence-based treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. The basivertebral nerve ablation procedure with the Intracept device is not the best available treatment for this patient based on clinical evidence of other pain etiology, such as facet arthrosis. Clinic notes state that on exam the patient has pain over facet joints and positive facet loading bilaterally. MRI notes that at L4-5 there is bilateral facet joint arthrosis, peri facet bone marrow edema, and short tau inversion recovery (STIR) signal hyperintensity involving the peri facet soft tissues. 

There are other evidence-based medications and treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

Despite FDA approval, Centers for Medicare & Medicaid (CMS) guidelines limit the use of basivertebral nerve ablation to a very select group of patients, who do not have evidence of other pain etiology, such as lumbar facet arthrosis. The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. 

In summary, the denial of 64628 Thermal destruction of Intraosseous Basivertebral Nerve, including all Imaging Guidance, first 2 Vertebral bodies, 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 and the adverse risks are substantially increased over standard treatments.