Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic pain

Treatment: service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied coverage for service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is overturned. 

This is a female patient who has been recommended to undergo the Intracept procedure. The patient had complaints of back and leg pain. The patient had complaints of back pain that radiated into the lower extremities. The pain was exacerbated with increasing physical activity which has limited her function and ability to perform activities of daily living. She also had complaints of worsening bilateral knee pain. The current medication regimen did allow her the ability to function without any adverse events. Physical examination revealed normal strength to the extremities. There was back pain rated at a 7/10 and the physician referenced prior imaging. The physician detailed the patient has spinal stenosis without neurogenic claudication and it was recommended she continue with medication use. She was also recommended to undergo the requested procedure and follow-up with a nutritionist for ongoing weight loss. Magnetic Resonance Imaging (MRI) indicated the patient had grade 1 anterolisthesis at the L4-5 level with bilateral facet hypertrophy resulting in mild right greater than left neuroforaminal narrowing and mild to moderate canal stenosis.

The medical literature notes that the Intracept Procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. It is noted that patients treated with radiofrequency ablation of the basivertebral nerve (BVN) for chronic low back pain (CLBP) exhibited significantly greater improvement in Oswestry Disability Index (ODI) at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain.

The patient has chronic pain despite prior conservative care. Given positive findings on MRI, to include Modic changes, the proposed procedure would be likely to be more beneficial than any other standard treatment.

The carrier's denial of service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) should be overturned.