Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.

Treatment: procedure to treat low back pain (procedure codes 64628 &amp;64629).

The insurer denied coverage for procedure to treat low back pain (procedure codes 64628 &amp;64629).

The denial is upheld.

In assessing whether intraosseous basivertebral nerve (BVN) ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly 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. Furthermore, despite Food and Drug Administration (FDA) approval, there are many exclusion criteria.

For individuals who have vertebrogenic low back pain who receive ablation of basivertebral nerves, the evidence includes two randomized controlled trials (RCTs) (SMART and INTRACEPT trials, both sponsored by device manufacturer Relievant Medsystems, Inc.). Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% of patients crossed over to the active treatment group and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Basivertebral nerve (BVN) ablation using the Intracept procedure is FDA approved in a very select group of patients who have - A history of chronic low back pain (cLBP) 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 L3 to S1; and - Activities of daily living that are limited by persistent low back pain; and - All other reasonable sources of pain have been ruled out.

Based on these criteria this patient is not a good candidate for intraosseous basivertebral nerve ablation. 

There are other evidence-based treatments available to this patient. 

This procedure is unlikely to be more beneficial than the standard approaches. 

The basivertebral nerve ablation procedure with the Intracept device is not the best available treatment for this patient based on evidence in the medical record of radicular pain. Clinic notes provided state that the patient's chronic low back pain radiates down the right lower extremity into her buttock and hamstring. She also complains of pain radiating down her left buttock and into her foot as well as some left groin pain. She also has some left anterior thigh numbness. MRI 
states that in addition to Modic endplate changes at L4-L5 there is also broad disc herniation at L3-L4 and right paracentral disc herniation at L4-L5 with right lateral recess stenosis and posterior displacement of the right L5 nerve root. Radicular pain that correlates with nerve compression on imaging was considered an exclusion criterion in the INTRACEPT study by Kahlil et al.

There are other evidence-based medications and treatments available to this patient. 

This procedure is unlikely to be more beneficial than the standard approaches. 

Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient.

In summary, the denial of procedure to treat low back pain (procedure codes 64628 &amp; 64629) 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.