Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain

Treatment: Procedure code 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; and 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

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; and 64629 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is upheld

According to the medical record, the patient is an adult female who presented on with a history of back pain. A magnetic resonance imaging (MRI) had shown previous kyphoplasty at T (thoracic) 12, chronic compression fracture and Modic type II changes at L (lumbar) 3 and L4-L5. The patient continued to have low back pain aggravated with leaning over. Her pain was averaging 4/10.

Per Conger, A. et al. (2022), "Conclusion According to GRADE (Grades of Recommendation, Assessment, Development, and Evaluation), there is moderate-quality evidence that BVN (Basivertebral nerve ablation) RFA (Radiofrequency ablation) effectively reduces pain and disability in most patients with vertebrogenic LBP (low back pain). Further high-quality studies will likely improve our understanding of the effectiveness of this procedure."

1. Does the scientific evidence in peer-reviewed literature support a result of improvement in health outcome?

No. There have been studies to support the use of basivertebral ablation for patients with Modic changes on MRI. Though the patient may benefit from this procedure, there was no documentation of patient having tried and failed all prior conservative treatments. No documentation of physical exam findings.

2. Do procedure codes 64628 and 64629 need/have final approval from the appropriate regulatory bodies for this diagnosis?

Yes. There have been studies to support the basivertebral nerve ablation for patients with Modic type I and II change.

3. Is this patient a good candidate for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 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)?

No. There have been studies to support the use of basivertebral ablation for patients with Modic changes on MRI. Though the patient may benefit from this procedure, there was no documentation of patient having tried and failed all prior conservative treatments.  No documentation of physical exam findings. As such, this patient is not a good candidate for procedure codes 64628 and 64629.

4. Is 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 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) the best available treatment for this patient at this time?

No. There was no documentation of the patient having tried and failed all prior treatments.

5. Are the adverse risks increased over standard treatment/services? No. 

The requested service is NOT more likely to be more beneficial than any of the standard treatment procedures for this patient. 

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 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) should be upheld.  It is not more beneficial than any other standard treatments.