Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral

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

The denial is upheld 

The insurer has denied coverage for Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral. In their Final Adverse Determination letter, they write that the doctor asked for a nerve treatment in the spine for low back pain. The plan medical policy states that this treatment is not shown to be effective to treat this pain and is not medically necessary or a covered service. 

The patient presented with intermittent left hip pain and had been provided with a steroid injection into the left hip area. A magnetic resonance imaging (MRI) failed to show any source of pain relating to the hip. The patient also saw a chiropractor, acupuncturist, and massage therapist. An MRI of the lumbar spine, according to the patient, revealed a bulging disc. An epidural block was performed and did not provide any relief. The Intracept procedure was recommended. This was denied and is being appealed. Tqazhe patient had a positive straight leg raising (SLR) test on the left side. Details regarding neurological evaluation are absent. The MRI shows a disc abnormality compressing the left sacral vertebrae (S) one (1) nerve root. 

"Low back pain is one of the most common musculoskeletal complaints encountered in clinical practice. It is the leading cause of disability in the developed world and accounts for billions of dollars in healthcare costs annually. Treatment is varied depending on the etiology and severity of symptoms. However, conservative management of symptoms is generally considered first line. Medications are used to manage pain symptoms including non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen, and in severe cases, opiates. Radicular symptoms are often treated with neuroleptic agents. Systemic steroids are often prescribed for acute low back pain, although there is limited evidence to support its use. Nonpharmacologic interventions are often utilized as well. Physical therapy, acupuncture, chiropractic manipulation, and traction are all commonly used in the treatment of lumbosacral radiculopathy. Of note, the data supporting the use of these treatment modalities is equivocal. Interventional techniques are also commonly used and include epidural steroid injections and percutaneous disc decompression. In refractory cases, surgical decompression and spinal fusion can be performed" (Alexander, C. E., & Varacallo, M. 2021).

Per Nwosu, M., et al., (2023), "Despite this, current research has demonstrated that the vertebral body endplate contributes significantly to the pathologic innervation linked to disc degeneration and transmits pain signals via the basivertebral nerve (BVN) (vertebrogenic pain)."

Based on the above, the insurer's denial of the above is upheld. The health plan acted reasonably with sound medical judgment and in the best interest of the patient.  

The medical necessity for Intracept Procedure for intraosseous ablation of basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and coverage for the requested treatment is not substantiated.