Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: (procedure code 64628) thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 
The insurer denied coverage for (procedure code 64628) thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 

The denial is upheld. 

The request for CPT (current procedural terminology) code 64628 thermal destruction of intraosseous basivertebral nerve with image guidance is under review. 

Supporting documentation reveals that this patient has a history of chronic lower back and neck pain and has trialed several conservative and non-conservative measures for this pain. Patient has received radiofrequency ablations in the lumbar spine which produced 70% pain in the past. According to overall documentation the patient is also taking opioids and other over-the-counter medications. Magnetic resonance imaging (MRI) was submitted, and patient has Modic changes at L (lumbar) 5-S (sacral) 1. The physician is recommending an intracept procedure. 

The current scientific evidence and peer-reviewed literature does not support a result improvement in health outcome. By definition more high-quality higher powered randomized controlled and larger sample size studies need to be conducted to fully understand the long-term efficacy as well as the risk profile exposure to the patient.
Lorio, M., Clerk-Lamalice, O., Beall, D. P., & Julien, T. (2020), "Intraosseous ablation of the BVN (basivertebral nerve) is a relatively new minimally invasive treatment for the relief of CLBP [chronic low back pain] that is diagnosed using well-established clinical and MRI findings. The procedure is supported by level 1 evidence including 2 RCTs (randomized controlled trial) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies. These results were seen in a patient population that is one of the most expensive and difficult to provide care for, and in this era of rising health care costs and increasing need for therapies to reduce the use of opioids, BVN [basivertebral nerve] ablation may provide a treatment option to fill the gap in the treatment paradigm for patients that fail nonsurgical treatment. 

LIMITATIONS 
(1) Industry funding is a potential source of study bias for the available data reviewed. 
(2) Limited number of studies. 
(3) Short-term follow up for the majority of studied patients. 
(4) Unknown effect on the primary degenerative process.

The procedure does not have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient would not be a good candidate for (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral. 

Adverse risks in the long-term setting need to be studied. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of procedure to treat low back pain (procedure code 64628) Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral should be upheld.