Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: A procedure to treat low back pain, code 64628, 64629.

The insurer denied coverage for a procedure to treat low back pain, code 64628, 64629.   
The denial is upheld. 

The patient has a history of low back pain beginning eighteen years ago. The patient's previous treatment includes back surgery (laminectomy and lumbar discectomy), medications, and physical therapy. Pain affects his ability to bend, lift and sit and interferes with sleep. It ranges from 4-6 on the VAS [visual analog scale] ranges. Beginning of this year an MRI [magnetic resonance imaging] showed Modic changes at L [lumbar] 3-4, L4-5 and L5-S1. A request for procedures using codes 64628 and 64629 was previously denied. This is the Intracept procedure for the treatment of vertebrogenic pain. This has been denied and is being appealed. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Further investigation by higher powered studies is needed to establish the short-term and long-term efficacy of this treatment as it pertains to this patient's pain. 

Schnapp, W., Martiatu, K., & Delcroix, G. J. (2023), "Our study demonstrates the feasibility and benefits of the basivertebral nerve ablation (BVNA) procedure when performed in a community practice setting and emphasizes the need to further study the best inclusion and exclusion criteria."

Michalik, A., Conger, A., Smuck, M., Maus, T. P., & McCormick, Z. L. (2021), "Basivertebral nerve (BVN) radiofrequency ablation appears to be an effective treatment for a subset of patients with chronic low back pain (CLBP) and evidence of Modic change types 1 and 2 in the L3 to S1 vertebral body endplates (VEPs) who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results." 

Francio, V.T., and Sayed, D. (2023), "Low back pain remains a global concern in healthcare. Diagnosing the source of low back pain remains a clinical challenge for healthcare providers, and often treatment interventions have a wide level of efficacy given poor specificity in the diagnosis. Among the hypothesized sources of low back pain, vertebral pain resulting from damaged vertebral endplates has gained attention with specific and reliable diagnostic criteria and several clinical studies reporting robust effectiveness data using intraosseous basivertebral nerve ablation as a targeted intervention in this subset of patients with low back pain of vertebral etiology."     

The procedure does not have final approval from the appropriate regulatory bodies for this diagnosis. The patient is not a good candidate for this procedure to treat low back pain. This procedure is not the best available treatment for this patient at this time.  The adverse risks are increased over standard treatment/services.  The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.           

In summary, the denial of a procedure to treat low back pain, code 64628, 64629, should be upheld. This treatment is not likely to be more beneficial than any standard treatments.