Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Lower Back Pain. 

Treatment: Procedure codes 22899, unlisted procedure, spine 64628- thermal destruction of intraosseous basiverterbral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629- thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 

The insurer denied coverage for procedure codes 22899, unlisted procedure, spine 64628- thermal destruction of intraosseous basiverterbral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629- thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 

The denial is upheld. 

This is a female with a history of hypothyroidism and spondylosis. She presented to the Pain Management physician's office for the evaluation of lower back pain. Pain was rated at a level of 8 out of 10. She had significant lumbar axial pain that had not responded to long term conservative treatment. Imaging revealed Modic changes at L (lumbar) 5-S1. The patient had a positive response to two lumbar medial blocks. The physician recommended proceeding with the Intracept procedure. 

The Intracept procedure is "intraosseous ablation of the basivertebral nerve." It has been proposed to address low back pain identified by Mobic changes. 

The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons nor spine surgeons. There are no National Organizations which provide guideline nor indication for its use. 

A search was performed using PubMed. The key word was Intracept Lumbar. There were two references. The articles submitted by appeal were also reviewed. There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely IRB (Investigational Review Board) The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. As such, at this time the Intracept procedure is not likely to be more beneficial than any standard treatments/procedures. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

This patient is not a good candidate for procedure codes 22899, unlisted procedure, spine 64628- thermal destruction of intraosseous basiverterbral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629- thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 

The adverse risks do not increase over standard treatment/services. 

The requested service is not likely to be more beneficial than any of the standard procedures for this patient. 

The carrier's denial of procedure codes 22899, unlisted procedure, spine 64628- thermal destruction of intraosseous basiverterbral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629- thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral should be upheld.