Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lower back pain

Treatment: Service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum

The insurer denied coverage for service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum.

The denial is upheld.

This is a male patient with a history of hypertension, benign prostatic hypertrophy (BPH), bilateral lower extremities lymphedema, hypercholesterolemia, anxiety and chronic low back pain who was under the care of a pain management physician for a complaint of lower back pain. The pain was aggravated by activity. The patient had consultations with physical therapists, a neurologist, and a chiropractor. He received injections, physical therapy, acupunctures, and home stretching. He has not had any surgical intervention. The patient was on Norco, Valium and methocarbamol medications. There was no significant relief on all of them. The patient had epidural steroid injections which provided some short term relief. Magnetic resonance imaging (MRI) of the lumbar spine revealed mild superior deformity of the lumbar vertebrae (L) 2 endplate, consistent with a chronic injury, minimal posterior bulging disc annulus, L1-2 with mild bilateral facet arthropathy, very small central and left lateral disc herniation, L2-3 with mild bilateral facet arthropathy and minimal reverse spondylolisthesis, mild left L3 root origin compression, minimal posterior bulging disc annulus, L3-4 with mild to moderate bilateral facet arthropathy, very mild thecal sac deformity, mild to moderate central broad-based disc herniation/ridge, L4-5 with mild degenerative disc narrowing and moderate bilateral facet arthropathy, mild thecal sac deformity and moderate bilateral L5 root origin compression, slightly more left-sided, moderate bilateral foraminal narrowing is present, right greater than left and subcortical marrow findings at the degenerated L4-L5 level are predominantly thoracic vertebrae (T) 1 and T2 hyper-intense, consistent with Modic type II changes.

This patient has disc pathology spanning from L1-L2 to L4-L5.  The physician proposes a two level radiofrequency ablation (RFA) of the intraosseous basivertebral nerves. In reviewing this procedure, UpToDate states "We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit." There is insufficient evidence to consider this technique safe and effective. The published studies do not adequately address multiple level procedures.

While the published evidence is favorable, only company sponsored studies have been published and only one study, which lost part of its control group due to cross-over therapy, extends to five years. Further, the studies have not included multi-level patients. The studies published have not had a head to head comparison with surgical intervention. This patient has not had surgical consultation documented. 

This procedure is not likely to be more beneficial than any of the standard procedures available to this patient.

The carrier's denial of coverage for service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum should be upheld.