Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: Intraosseous basivertebral nerve ablation, procedure code 64628

The insurer denied coverage for intraosseous basivertebral nerve ablation, procedure code 64628

The denial is upheld

The medical records indicate the patient has Spondylosis of the lumbar spine with Vertebrogenic pain. He is reported to have limited range of motion (ROM) in the lumbar spine. 

A magnetic resonance imaging (MRI) of the lumbar spine, completed on 05/26/2023, showed anterolisthesis of lumbar four and five (L4-5), narrowing of the lateral recesses, narrowing of the spinal canal, narrowing of the left foraminal and neural foramina and impingement of lumbar (L)5 and sacral (S)1 nerve roots. 

At this time, the provider is requesting approval for treatment with intraosseous basivertebral nerve ablation procedure, which is the topic of this review.

The scientific evidence in peer-reviewed literature does not support an improvement in health outcomes.

Current medical literature concludes that there is insufficient evidence to support the safety and efficacy of the intraosseous basivertebral nerve ablation procedure. Also, studies are limited by small sample sizes, lack of randomization and control as well as short term follow up. 

"Additionally, nonindustry-funded large-scale, high-quality trials with generalizable study participants are needed to confirm the results of the current studies and further assess the complications." (Nwosu, M., et al., 2023).

An industry-sponsored study, by Becker et al., (2017) assessed the efficacy of intraosseous basivertebral nerve (BVN) ablation, with the Intracept system, in 17 patients with chronic low back pain. Sixteen patients were treated successfully. Self-reported outcome measures were collected prospectively at each follow-up interval. There was a significant decrease in the average Owestry Disability Index (ODI) at 3 months postoperatively, which was maintained at 12 months. Significant improvement in the Visual Analog Scale (VAS) scores and quality of life were also reported at the 3-month follow-up.

However, this study involves a very small subject group and is industry sponsored; therefore, it should not be taken into consideration when deciding medical appropriateness of this procedure. The majority of current literature for the intraosseous basivertebral nerve ablation involves small groups of participants and further studies are needed. 

Intraosseous basivertebral nerve ablation, procedure code 64628 does not have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for intraosseous basivertebral nerve ablation, procedure code 64628.     

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

The adverse risks are increased over standard treatment/services.     

The requested service, intraosseous basivertebral nerve ablation, is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

Surgical intervention is only warranted if the patient fails a conservative management trial of at least 6 months or has progressive neurologic symptoms with saddle anesthesia, bowel/bladder dysfunction, refractory pain, or develops spondylolisthesis of grade 3 or higher. The most commonly performed surgical treatments of spondylolysis include a direct repair of the defect in the pars interarticularis at L1 to L4 levels and an inter-transverse fusion for defects at the L5 level." (McDonald, B. T., Hanna, A., & Lucas, J. A. 2023).                                                    

In summary, the denial of intraosseous basivertebral nerve ablation, procedure code 64628 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.