Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic vertebrogenic pain.
Treatment: Procedure codes 64628 & 64629 to treat low back pain.

The insurer denied coverage for procedure codes 64628 & 64629 to treat low back pain.  The denial is overturned.

The patient is a male with a diagnosis of low back pain. The request is an appeal to perform two procedures: code 64628 - thermal destruction of intraosseous basivertebral nerve and 64629 - thermal destruction of intraosseous basivertebral nerve. 

According to the medical record, the patient was being evaluated for chronic cervical and lumbar "degenerative spine disease". He had undergone several recent conservative treatment modalities, including steroid injections and nerve ablations. His physical exam documented "trigger points notable bilaterally in the lumbar spine muscles." The plan at that time was to proceed with trigger point injections and the Intracept procedure. 

The patient was seen on another visit and provider documents that the patient has had chronic, worsening, right sided neck, and back pain. He had undergone other conservative treatment modalities without relief, including chiropractic care, injections, acupuncture, and massage. His physical exam documents a positive Kemp sign and multiple quadratus trigger points. A lumbar spine magnetic resonance imaging (MRI) scan reportedly showed Modic type I changes lumbar three to five (L3-5), disc herniation, and interval worsening disc degeneration. An MRI of the cervical spine reportedly shows multilevel spondylosis, worse at cervical three through four (C3-4) and cervical five through six (C5-6). The plan was to refill the patient's pain meds and plan for radiofrequency ablation.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. There is good evidence to support using code 64628 and 64629 - thermal destruction of intraosseous basivertebral nerve, for conservative treatment of cervical and lumbar pain. 

The codes have final approval from the appropriate regulatory bodies for this diagnosis. The United States (US) Food and Drug Administration (FDA) approved Intracept as a radiofrequency ablation device that targets the basivertebral nerve, for the treatment of chronic low back pain.     

This patient is a good candidate for the procedure codes as he has failed to improve with other conservative modalities for the past six months. There are no other risk factors indicating that he is at high risk for complication for the procedure.     

The codes are the best available treatment for this patient at this time. This is the best available option. It is a safe option with reproducible outcomes based on the available research. The patient has failed to respond to many other conservative measures.    

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The requested procedure has been tested in prospective studies that compare the nerve ablation intervention to standard treatment. It has shown favorable outcomes with a good safety profile. This patient suffers from low back pain. He had undergone several recent conservative treatment modalities, including steroid injections, nerve ablations, chiropractic care, acupuncture, and massage. This is the best available option for this patient.

The carrier's denial of procedure codes 64628 & 64629 to treat low back pain should be overturned.