Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The insurer denied coverage for procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.
The denial is upheld.

This patient has low back pain. Pain was rated at a 7-9 out of 10. The patient has tried and failed physical therapy (PT), injections, lidocaine patches, prednisone, and naproxen without relief. Imaging revealed mildly progressed multilevel degenerative disc of the lumbar spine mildly increased paraspinal muscle atrophy. The physician recommended the Intracept procedure to treat back pain.		

The publications to date have been company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The Spine Society makes no mention of the Intracept procedure or ablation of the basivertebral nerve (BVN) using radiofrequency. 

The Intracept procedure has final approval from the appropriate regulatory bodies for this diagnosis. Intracept is medically indicated in patients who have - A history of low back pain of at least 6 months duration; and failed to respond to at least 6 months of non-surgical management; and - Magnetic resonance imaging (MRI) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L (lumbar) 3 to S (sacral) 1; and - Activities of daily living that are limited by persistent low back pain; and - All other reasonable sources of pain have been ruled out.

The patient is not a good candidate for the procedure. There are other evidence-based procedures available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. 

Based on the provided MRI report, this patient had "Modic 1 marrow signal changes at L1-2, Modic 2 at other segments." Therefore, based on the above evidence, procedure code 64628, thermal destruction of intraosseous basivertebral nerve is not necessary at this time for this patient.

The requested procedure is not the best available treatment for this patient. There are other evidence-based medications and treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

The adverse risks are increased over standard treatment/services. Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

Based on the MRI findings of Modic changes at multiple lumbar levels, along with MRI findings of potential other causes for her pain, and lack of documentation of evidence based nonpharmacologic treatment, the Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient.
The insurer's denial of coverage for procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure) is upheld.