Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The denial is upheld.

The patient is an adult male with chronic low back pain of several years' duration. He has trialed multiple treatments including acupuncture, chiropractic care, heat/ice, injections, lumbar epidural steroid injections, medial branch block injections, medications, and physical therapy. The pain greatly impacts his ability to complete activities of daily living especially with 
changing positions. Nothing has provided sustainable relief. His pain ranges from 6-10/10. Magnetic resonance imaging (MRI) of the lumbar spine with Modic changes at disc spaces L3-4, L4-5, and L5-S1 according to provider review. Official radiology read with multilevel degenerative changes and showed no report of degenerative endplate changes or Modic changes. Physical exam revealed 5/5 strength, negative Hoffman's sign, positive straight leg, and negative sacroiliac joint and facet loading maneuvers. The provider requested basivertebral ablation of L3, L4, L5, and S1 vertebral bodies to treat vertebrogenic pain. This was denied by the health plan as investigational/experimental. The denial is being appealed.

The health plan should not cover the requested health service.

The Intracept procedure is a relatively novel procedure used to treat vertebrogenic axial back pain. In properly selected patients with chronic low back pain, the SMART and SMART 24 randomized controlled trials (RCTs) demonstrated significant pain relief. In fact, close to 50% of the patients were able to cease opioid use for chronic low back pain. The procedure has been proven safe and effective and is United States Food and Drug Administration (FDA) approved. Treatment should be considered when all conservative measures have tried and failed and when the patient has clear Modic changes on magnetic resonance imaging. There is level 1 evidence for its safety and efficacy and, therefore, it would not be considered experimental/investigational for properly selected patients. The cohorts used in the SMART and SMART 24 trials were large (over 200 people) with statistically significant results. More recent 5-year data from the ongoing SMART study demonstrated that 66% of patients reported 50% reduction in pain, 47% reported a greater than 75% reduction in pain, and 34% had complete pain resolution. As mentioned by the provided appeal letter, clinical summary, and robust reference bibliography, several societies including American Society of Pain and Neuroscience (ASPN) and North American Spine Society (NASS) have given basivertebral nerve (BVN) ablation level A grade evidence with high certainty that the net benefit is substantial in appropriately selected pain patients. The patient in this case has had chronic low back pain for more than 6 months; has failed conservative treatment including medications, injections, physical therapy, and acupuncture; and has significant functional decline and inability to complete activities of daily living due to his pain. However, the reported magnetic resonance imaging of the lumbar spine is from 2 years ago, and there is no official read noting Modic changes and/or endplate degenerative changes as reported by the requesting provider. Therefore, this procedure is not considered medically appropriate for this patient.