Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1 

Diagnosis: Low back pain

Treatment: Lower back spinal nerve thermal (heat) destruction, code 64628

The insurer denied coverage for lower back spinal nerve thermal (heat) destruction, code 64628

The denial is upheld

The patient underwent a medical branch block at lumbar (L) 3 to L4, L4 to L5 and L5 to sacral (S1) levels. He has had an above knee amputee (AKA). The patient had a pulmonary embolism and takes Eliquis for management. He has evidence of facet arthropathy. Magnetic resonance imaging (MRI) scan of the lumbar spine showed Modic type one and type two changes affecting the vertebral bodies at L1,L4 to L5. Prior treatment includes selective root blocks at L4 to L5 and L5 to S1, epidural injections (EI). Another MRI of the lumbar spine showed disc bulges at multiple levels with no change compared to the prior studies. 

There is no scientific evidence in peer-reviewed literature to support a result of improvement in health outcome. All the clinical details provided relate to facet arthropathy and nerve root irritation. There is no basis to suspect the pain generator to emanate from the vertebral body.      

The requested procedure does not have the final approval from the appropriate regulatory bodies for these diagnoses. Final approval from the regulatory bodies for these diagnoses has not occurred. Food and Drug Administration (FDA) approval was granted for Modic changes only.

This patient is not a good candidate for the requested procedure. It is not the best available treatment for this patient at this time. The adverse risks are increased over standard of care treatments and/or services. 

The treating provider is requesting plan approval for lower back spinal nerve thermal, heat, destruction, code 64628 for the treatment of a history of vertebrogenic pain, facet arthritis of lumbar region, spondylosis of lumbar spine, chronic sacroiliac joint pain, degenerative disc disease (DDD), and discogenic low back pain.

"Many common causes of low back pain cannot be verified by diagnostic tests. These include the presence of muscle strains, ligament sprains, or small tears of the annulus fibrosis of the disk, which seem intuitively plausible as causes of pain. Other possible diagnoses such as facet joint arthritis (degenerative joint disease), sacroiliac joint asymmetry, or disk bulges do not correlate statistically with the presence of pain in large populations, nor with reproduction of pain or alleviation of pain on examination or injection in studies with designs to control potential biases. Some causes fit into well-documented syndromes such as disk herniation, spondylolisthesis, or spinal stenosis. Even in these cases the diagnosis is often not simple. For example, one-third of asymptomatic volunteers have disk changes on MRI. Neither the radiologist's report of stenosis nor measures of the spinal canal on imaging are useful in positively diagnosing the clinical syndrome of spinal stenosis. Low-grade spondylolisthesis noted on x-ray is most often asymptomatic. In these cases, diagnostic tests must be interpreted in conjunction with the clinical history and physical examination." (Chiodo, et al., 2020)

The patient needs to trial and fail conservative treatment and exercise programs, such as physical therapy, or documentation stating these have been trialed. There is no documentation showing superiority of the requested treatment over the standard of practice.                                                    

In summary, the denial of lower back spinal nerve thermal (heat) destruction, code 64628 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.