Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic lower back pain
Treatment: procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept).

The insurer denied coverage for procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept).

The denial is overturned. 

The patient is an adult male with a history of low back pain and right knee pain. The patient has a long history of back pain and coccyx pain of over 10 years. The patient had prior epidural steroid injection (ESI) with moderate relief and sacroiliac (SI) joint injection without relief. The patient had temporary relief with prior physical therapy as well as acupuncture. The patient also had prior bilateral medial branch block, and radiofrequency ablation (RFA). Pain was described as sharp, aching and aggravated with running, bending over, sneezing, and bowel movements. Exam shows facet loading mild to moderate pain bilateral. Diagnoses include coccydynia, degenerative disc disease (DDD), lumbago, and lumbar spondylosis. Magnetic resonance imaging (MRI) showed Modic type I changes at L (lumbar) 5 and S (sacral) 1 and degenerative changes.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

Loan, A.J., and Kieser, D.C. (2021) write, "This study supports the conclusion that radiofrequency ablation of the basivertebral nerve is a safe and effective treatment for discogenic chronic low back pain."

Finally, Michalik, A., Conger, A., Smuck, M., Maus, T. P., & McCormick, Z. L. (2021) write, "Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment."

The patient has a history of chronic low back pain despite prior conservative treatments including physical therapy, activity modification, epidural injection, and radiofrequency ablation. The patient continues to be symptomatic. MRI showed Modic type I changes at the area being treated. Given the patient's history and current studies, the requested procedure is supported in this case and is recommended for this type of diagnosis. Therefore, patient would be a good candidate.

Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) is the best available treatment for this patient at this time. 

The risks are the same with any type of procedure. In this case there have been studies that support of the requested procedure. The procedure is minimally invasive.

Given patient's history, the requested procedure would be more beneficial than any of the standard treatments/procedures for this patient. The patient has tried and failed all other prior treatments with minimal improvement.

The insurer's denial of procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) should be overturned.