Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain

Treatment: 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first two vertebral bodies, lumbar or sacral (Intracept), 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure (Intracept)

The insurer denied coverage for 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first two vertebral bodies, lumbar or sacral (Intracept), 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure (Intracept)

The denial is upheld

Reviewer #3:

The patient is seeking coverage for 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first two vertebral bodies, lumbar or sacral (Intracept) and 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure (Intracept).  The patient was diagnosed with vertebrogenic pain, degenerative disc disease, and lumbar herniated disc.

Magnetic resonance imaging (MRI) of the patient's lumbar spine noted that the L1-2 levels were normal.  At L (lumbar) 2-3, there was a left-sided disc herniation that indented at the anterior aspect of the thecal sac and extended into the left L2-3 foramen.  There was no central spinal stenosis.  The right L2-3 foraminal was patent.  The L3-4 and L4-5 levels showed postoperative changes.  There was degenerative disc disease without evidence of extrinsic compression of the thecal sac.  The neural foramina were patent.  At L5-S (sacral) 1, there was central disc herniation that indented the anterior aspect of the thecal sac.  There was moderate bilateral L5-S1 foraminal stenosis.

The patient presented for an evaluation related to back pain that had been ongoing for 3 years.  The patient reported a history of car accident.  The patient had been left with back pain that was worsened with sitting for more than 20 to 30 minutes.  The patient would occasionally get sciatica down the left leg.  Epidural steroid injections had been helpful.  The axial pain bothered the patient the most.  The patient rated their pain at 7 out of 10.  Chiropractic treatment provided minimal relief of symptoms.  Physical therapy tended to aggravate the symptoms.  The patient participated in a home exercise program.  However, their activities of daily living were significantly affected with 10 out of 10 pain with more than 30 minutes of sitting despite modification.  The patient had utilized Tylenol and Motrin.  The physical exam findings of the patient noted pain with flexion of the lumbar spine.  The patient had 5 out of 5 strength in the bilateral lower extremities.  There were no sensory deficits.  The straight leg raise testing was negative.  The facet joint loading maneuver was negative.  Palpation over bony landmarks was nontender.  

In summary, the denial of 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, first two vertebral bodies, lumbar or sacral (Intracept), 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance, each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure (Intracept) and coverage for the requested service should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.