Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain

Treatment: Intracept procedure, codes 64628 thermal destructions of the intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 thermal destructions of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

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

The denial is upheld. 

The insurer has denied coverage for Intracept procedure, codes 64628 thermal destructions of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629 thermal destructions of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral, as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has lower back pain. 

This patient has chronic low back pain. The pain has had Physical therapy and a Home exercise program. The patient has had Medial branch blocks and then radiofrequency ablation (RFA). The patient has also had Epidural Steroid injections and sacroiliac (SI) joint injections. The patient's medications are non-steroidal anti-inflammatory drugs (NSAID) and Xanax. The patient's magnetic resonance imaging (MRI) shows disc degeneration, facet arthropathy, and Modic changes at lumbar (L)3, L4, and L5. The request is for RFA of the Basivertebral nerves (BVN) at those levels. 

The publications to date have been company sponsored and had methodological flaws.  There is no published data on long-term complication rates.  A Hayes technology assessment3 has evaluated this procedure and concluded that it is still investigational.  There are other evidence-based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al.4 pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. The success of the procedure appears to be dependent on the effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline5 while favorable pointed out the limitations of the current literature:

-	Industry funding is a potential source of study bias for the available data reviewed.
-	A limited number of studies.
-	Short-term follow-up for the majority of studied patients.
-	Unknown effect on the primary degenerative process

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Intracept procedure, codes 64628 thermal destructions of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629 thermal destructions of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral is not substantiated. The insurer's denial is upheld.