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 overturned.

This is a male patient who has a chronic history of low back pain. The pain is decreased by medications as well as rest and injections and is aggravated with activity. The patient has had prior treatment with physical therapists as well as chiropractic care and injections. The patient has also participated in acupuncture and stretching. His pain was disabling, affecting his quality of life on a daily basis.  

The patient's pain has persisted for greater than 4 years. All traditional non-operative measures have been exhausted. It has been recommended that the patient undergo destruction of intraosseous basivertebral nerve, first 2 vertebral bodies including imaging guidance. Magnetic resonance imaging (MRI) revealed mild superior lumbar vertebrae (L) 2 endplate deformity consistent with chronic injury. There was minimal posterior bulging disc annulus at L1-2 with mild bilateral facet arthropathy as well as a very small central and left lateral disc herniation at L2-3 with minimal posterior bulging disc annulus at L3-4 with mild to moderate bilateral facet arthropathy. There was also mild to moderate central broad-based disc herniation/ridge at L4-5 with mild degenerative disc narrowing and moderate bilateral facet arthropathy. There was mild thecal sac deformity and moderate bilateral foraminal narrowing was also present.  At the L5-S1 (lumbosacral) level there was a minimal posterior disc bulge with bilateral facet arthropathy and a 5 millimeter left foraminal synovial cyst. There was also mild deformity of the exiting L5 root with foraminal neurocompression. An addendum indicated the subcortical marrow findings of the degenerated L4-5 level with predominantly thoracic vertebrae (T) 1 and T2 type hyper-intense which is consistent with Modic type II changes.

Based on the documentation provided and per peer-reviewed literature, the requested procedure does support a result of improvement in health outcome. The patient has a history of chronic axial pain and despite prior treatments including injections, physical therapy, chiropractic care, and acupuncture as well as medication, the patient continues to be symptomatic. Imaging does show Modic type II changes which is supported for the use of this procedure. This is the best available treatment for this patient at this time. The patient has tried and failed all prior conservative treatments. This procedure is likely to be more beneficial than any other standard procedures since the patient has tried and failed all prior treatments. 

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 overturned.