Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low back Pain. 
Treatment: 22899, unlisted procedure, spine. 

The insurer denied coverage for 22899, unlisted procedure, spine.  The denial is upheld. 

The patient has a history of low back pain that began several years ago, which has been worsening over the last few months. She has had multiple treatments that include chiropractic care, heat/ice, home exercises, laminectomy, medial branch block injections, medication management, physical therapy, radiofrequency ablations, transforaminal epidural steroid injections, and a sacroiliac (SI) joint injection. She has a history of a lumbar (L) two (2)-L3 laminectomy. A Magnetic resonance imaging (MRI) of the lumbar spine showed a small disc bulge at L3, L four (4), L five (5). 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. The studies for Nerve Ablation for the Treatment of Chronic Low Back Pain have strict criteria. 

"Exclusion criteria: Radicular pain (any pain that traveled along a dermatomal distribution into the lower extremity, causing pain, numbness, and/or weakness/heaviness of the affected area) Previous lumbar spine surgery Symptomatic spinal stenosis (defined as the presence of neurogenic claudication and confirmed by imaging) Diagnosed osteoporosis (T < 2.5) Disc extrusion or protrusion > 5 mm [millimeters] Spondylolisthesis > 2 mm at any level 3 or more Waddell's signs Beck Depression Inventory > 24 Involved in litigation related to back pain or injury or receiving disability compensation Currently taking extended release narcotics." (Fischgrund JS, et al., 2019). 

CPT 22899, unlisted procedure, spine is Food and Drug Administration (FDA) approved in the treatment of chronic low pain and typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes. The patient is not a good candidate for 22899, unlisted procedure, spine. She has multiple complaints of pain with a failed surgery. In addition, an MRI (magnetic resonance imaging) did not show modic changes associated with low back pain.  22899, unlisted procedure, spine is not the best available treatment for this patient at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. It is unlikely to be beneficial for this person given her chronic pain. She has multiple complaints of pain with a failed surgery. In addition, an MRI did not show Modic changes associated with low back pain.     

The adverse risks for the requested procedure are increased over standard treatment/services. It is a new interventional procedure with a learning curve and does involve cannulating bone. Therefore, it is more serious than an interventional procedure.  

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. It is unlikely to be beneficial for this patient given her chronic pain. She has multiple complaints of pain with a failed surgery. In addition, an MRI did not show Modic changes associated with low back pain. 
 
The carrier's denial of 22899, unlisted procedure, spine should be upheld.