Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The insurer denied coverage for the 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The denial is upheld. 

The patient has a history of low back pain which is associated with falls. A request was made for her to undergo thermal destruction of the intraosseous basivertebral nerve of the first 2 vertebral bodies. The request was denied. In an appeal it is noted that the patient has received lumbar epidural steroid injections, medial branch block injections, and radiofrequency ablations. She has also had multiple medications. In the physical examination there was no neurological deficit noted. 

The scientific evidence in peer reviewed literature does not confirm or support improvement in the health outcome. 

Based on recent and relevant peer literature this procedure is not considered the most effective treatment available. At this time, non-industry funded high-quality, large prospective studies are needed to establish the long-term efficacy of this treatment as it pertains to this patient's pain. Therefore, the request for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral  is not likely to be the most effective treatment available. 

The 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and 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. 

The requested treatment is not the best available treatment for this patient at this time.     
  
The adverse risks are increased over stand treatment/services. 

The requested service is not likely to be more beneficial than any of the standard treatment 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 (Intracept) and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 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.