Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic low back pain

Treatment: current procedural terminology (CPT) code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral.

The insurer denied coverage for current procedural terminology (CPT) code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral.

The denial is upheld.

 
This woman has chronic low back pain. Her medication trials have included: Meloxicam, Methocarbamol, Oxycodone, Percocet, Prednisone, Tramadol and Valium. She has had an Epidural Steroid injection.  Physical therapy and Occupational Therapy (OT) consultation were ordered in April. Her magnetic resonance imaging (MRI) showed Modic changes at lumbar (L)4 and L5.  Also noted at that level was an L4-L5 Disc Bulge with bilateral neuroforaminal stenosis as well as spinal stenosis.  An L5-sacral (S)1 disc protrusion was also noted.  There is no documentation of a surgical consultation. 

The publications to date have been company sponsored and had methodology flaws.  
There are no published data on long-term complication rates. There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

-  Industry funding is a potential source of study bias for the available data reviewed.
-  Limited number of studies.
-  Short-term follow up for the majority of studied patients.
-  Unknown effect on the primary degenerative process

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large randomized controlled trials (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of radiofrequency (RF) ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for current procedural terminology (CPT) code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral is not substantiated.