Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic

Treatment: Procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation))

The insurer denied coverage for procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)).

The denial is overturned.

This case involves a request for surgical intervention.  Magnetic Resonance Imaging (MRI) of the lumbar spine revealed diffuse disc bulge at L [lumbar] 4-5 indenting upon the ventral thecal sac with mild spinal canal stenosis.  The patient also had bilateral lateral recess narrowing and indention upon the descending bilateral L5 nerve roots.  There was also mild lateral foraminal narrowing.  There was also noted to be T1 [weighted] hypointense and T2 [weighted sans]/flair hyperintense 40 mm (millimeter) focus within the central portion of the S [sacral] 1 vertebral body with possibilities including nonspecific, atypical hemangioma, or prominent basivertebral plexus.  There was Modic type I endplate changes at L4-5.  The patient was seen for a history of chronic low back pain.  The patient also reported some intermittent numbness from the left hip.  The patient reported that symptoms affected activities of daily living.  Past treatment included physical therapy, acupuncture, facet joint injections, sacroiliac joint injections, paraspinal musculature injections, chiropractic treatment, and medication management.  Physical examination revealed lumbar spine tenderness and pain with range of motion.  The patient had negative straight leg raise, symmetric reflexes, and normal strength.  The patient was recommended for fusion at L4-5.  History and physical reported the patient had chronic back pain severely debilitating her activities of daily living.  It was noted there was no associated radiculopathy and the patient had concordant pain at L4-5 on discogram.  Treatment plan included basivertebral nerve ablation.  

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.  Scientific literature supports that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in Owestry disability index (ODI) and visual analog scale (VAS) and maintained high responder rates years following treatment.  Per the International Society for the Advancement of Spine Surgery guideline, intraosseous ablation of the basivertebral nerve from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain of at least 6 months duration when there is failure to respond to months of nonsurgical management, and MRI demonstrated Modic change 1 or Modic change 2 in at least 1 vertebral endplate at 1 or more levels from L3 to S1.  In this case, the patient has a history of chronic low back pain with failure of conservative care.  The patient has radiologic findings of Modic type I endplate changes consistent with causing vertebrogenic pain. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  The procedure code C9752 for the treatment of low back pain (Intracept Procedure (Intraosseous basivertebral nerve ablation)) has final approval from the appropriate regulatory bodies for this diagnosis.  The patient is a good candidate for procedure code C9752 for the treatment of low back pain (Intracept Procedure (Intraosseous basivertebral nerve ablation)).  The procedure code C9752 for the treatment of low back pain (Intracept Procedure (Intraosseous basivertebral nerve ablation)) is the best available treatment for this patient at this time.  Alternatives include possible fusion. 

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

Based on the above, coverage for procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)) should be overturned.