Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain.

Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

The insurer denied coverage for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral.

The denial is overturned.

This case involves an adult patient diagnosed with ankylosing spondylitis, lumbar degenerative disc disease, lumbar spondylosis, and a lumbar herniated disc who was being recommended for the Intracept procedure to treat the lumbosacral spine. Magnetic resonance imaging (MRI) of the lumbar spine revealed stable abnormal degenerative change without significant central spinal canal stenosis, mild stenosis subarticular recesses bilaterally at lumbar (L) 4- L5 with multilevel neuroforaminal stenosis most pronounced at L5- sacral (S) 1 with mild impingement of the exiting L5 nerve root. Prior relevant treatment included physical therapy, chiropractic care, heat/ice, over-the-counter medications, and a transcutaneous electrical nerve stimulation (TENS) unit. She responded well to transforaminal epidural steroid injections and had undergone lumbar medial branch blocks with equivocal response to sacroiliac joint injections. The physician submitted a request for prior authorization for the Intracept procedure to treat chronic vertebrogenic pain. The physician endorsed that the patient met criteria for this procedure given chronic low back pain due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplate changes (Modic changes) on MRI. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. The requested procedure has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the procedure. The procedure is the best available treatment for this patient at this time. 

Intraosseous radiofrequency ablation of the basivertebral nerve is an effective and durable therapy for low back pain and can be offered to patients who have chronic low back pain of greater than 6 months of duration, failure to respond to noninvasive therapies for 6 months, with either Modic Type I or Type II changes at L3-S1. The most widely used and studied technique (The Intracept Procedure, Relievant Medsystems Inc) has demonstrated consistent, statistically significant, clinically meaningful, and durable improvements in pain and function, as well as an excellent safety profile. 

The patient had been undergoing treatment for what was found to be degenerative disc disease in the lumbar region. She failed to sufficiently respond to multiple modalities of treatment and was being recommended for the Intracept procedure. Given the findings on examination and diagnostic imaging, the patient was a suitable candidate for the proposed treatment. The Intracept procedure has been found safe and effective, is now being used as a mainstream treatment for patients with this condition. 

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments. 

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral should be overturned.