Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: procedure code 64628 (intraosseous basivertebral nerve ablation)

The insurer denied coverage for procedure code 64628 (intraosseous basivertebral nerve ablation)

The denial is upheld 



This case involves a patient seeking authorization for the coverage of Intracept procedure.  A magnetic resonance imaging (MRI) of the lumbar spine revealed mixed Modic type II and III endplate changes at L (lumbar) 5-S (sacral) 1. Stable degenerative spondylosis in the lower lumbar spine resulting in foraminal stenoses. 

The patient was seen in the clinic for follow up of their chronic pain. The provider indicates that the patient has a history of brachial plexopathy following rib resection for thoracic outlet syndrome.  The pain has been ongoing for approximately 10 years. The provider stated that the patient has been opiate dependent for the management of their chronic pain for quite some time.  The patient is currently on Lyrica 200 milligrams (mg) twice daily, and Xtampza extended-release (ER) 13.5 mg twice daily.  The patient reported that overall, their medication regiment typically decreases their pain from 7/10 to 4-5/10 which improves their function with day-to-day activities.  The provider also stated that the patient also has a history of chronic lower back pain for several years.  MRI of the lumbar spine is significant for degenerative disc disease at L4-L5 and L5-S1, with Modic endplate changes at L5-S1.  The patient denies any radiating pain, numbness, or weakness down the lower extremities.  The patient reports lower back pain is significantly elevated by bending forward such as when tying their shoes, leaning forward to wash dishes or give their child a bath.  Lumbar epidural steroid injections (ESI) has been minimally effective.  The provider indicated that the recommended treatment to address his chronic vertebrogenic pain is basivertebral nerve ablation.  The patient's chronic lower back pain has been unresponsive to lumbar surgery, ESI, opiates, non-steroidal anti-inflammatory drugs (NSAIDs), and neuropathic medication.  

The provider's letter indicates that the patient has a chronic history of low back pain that began over 10 years ago.  The provider stated to address the patient's pain they have had the following treatments: Back surgery, injections, lumbar epidural steroid injections, medication management, and trigger point injections.  Medications have included: Acetaminophen, Lyrica, NSAIDs, opiate analgesics, and oxycodone.  The pain has had a significant impact upon patient's activities of daily living (ADLs) such as bending, lifting, and twisting.  The provider noted that nothing has provided significant sustainable relief.  The provider stated that the patient's condition has been characterized by a visual analog scale (VAS) score of 4/10 and 7/10.

Based on the medical records, lack of evidence to establish the safety and efficacy of intraosseous radiofrequency ablation (RFA) of the basivertebral nerve for treating low back pain with radicular pain, symptomatic spinal stenosis, and prior lumbar surgery, the requested procedure of intraosseous basivertebral nerve ablation does not meet approval criteria in this patient.

In summary, the denial of procedure code 64628 (intraosseous basivertebral nerve ablation), date of service to be determined, to be performed at Health Alliance Hospital Broadway campus and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.