Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative disc disease

Treatment: Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation)

The insurer denied coverage for Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation).

The denial is upheld.

The patient is an adult male with a history of low back pain. Treatment has included home exercises, laminectomy, medial branch block injections, percutaneous lysis of epidural adhesions, sacral coccyx joint and sacrococcygeal ligament injection, sacroiliac joint injections and radiofrequency neurolysis, bilateral superior cluneal nerve blocks and epidural steroid injection at L (lumbar) 3-L4, medications and radiofrequency ablations. His pain is rated 9/10 and he has difficulty with activities of daily living. He has not had any sustained relief with treatment. His exam notes pain across the lumbosacral junction with a limited range of lumbar motion. He has some pain with extension but severe pain with flexion from 15-30 degrees. He describes a catching sensation while bending down. He has lumbar muscle spasm and facet tenderness with predominant pain in the midline and pain across his lumbosacral junction appears to be anterior column spine pain. His MRI (magnetic resonance imaging) shows disc changes with inflammation, endplate changes with Modic type I and 2 at L5-S (sacral) 1 more predominant. He had a previous lumbar disc herniation that migrated down on the left side but has no lower extremity symptoms. His diagnoses list degenerative disc disease lumbar, discogenic low back pain, and vertebrogenic pain. 

A lumbar x-ray notes probable narrowing of the neural foramina L5-S1, Limbus vertebra of L3 and mild depression of the superior endplate of T (thoracic) 12. A lumbar flexion/extension x-ray notes mild lower lumbar spine degeneration with minor osteophytic spurring, mild disc space narrowing L5-S1, and L3 limbus vertebra. No change on flexion/extension views. A lumbar MRI notes previous disc surgery with left laminotomy L5-S1, prominent discogenic signal changes surrounding endplates at L5-S1 with progression and a larger Schmorl's node indenting the inferior L5. Some edema signal extends to the mid portions consistent with Modic type 1 signal with
superimposed areas of Modic 2. There remains mild soft tissue along the left ventral epidural space which is probably extending into the left lateral recess causing displacement of the left S1 nerve root posteriorly. There remains some left medial facet overgrowth and foraminal stenosis greater on the right. At L4-L5 some ligamentum flavum hypertrophy and facet disease. L3-4 congenital short pedicles with bilobed disc bulging superimposed with minimal encroachment upon the bilateral foramina. Mild facet and ligamentum flavum hypertrophy at L2-3 with minimal Modic 1 signal change.

The patient is not a good candidate for CPT (Current Procedural Terminology) 64628. He has had a prior laminectomy at the requested level with scar tissue. He also has disc and facet disease that could be causing his symptoms. Furthermore, the Intracept procedure is not studied on prior performed surgical levels. 

The Intracept procedure is not supported by current and peer reviewed medical literature for this patient's clinical scenario. There is no indication that this procedure is safe or effective for this patient as he has had a prior laminectomy/discectomy at the level being requested and it is not clear that his pain generator is from the vertebral bodies. The patient also has significant pathology at the L5-S1 level that will most likely not respond to this procedure.

In summary, the denial of Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation) should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition.