Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Procedure to treat low back pain (procedure codes 64628 and 64629)

The insurer denied coverage for procedure to treat low back pain (procedure codes 64628 and 64629)

The denial is overturned

Reviewer #2:

This case involves a patient seeking authorization for the coverage of Intracept procedure or thermal destruction of the intraosseous basivertebral nerve (BVN).

The patient presented in the clinic with a complaint of debilitating chronic low back pain (CLBP). The patient reported that they started having back pain dating back several years when they hurt their back while moving furniture. The patient reported that they were diagnosed with a disc injury. The patient underwent extensive physical therapy, injections, and activity modification without improvement. The patient stated that they were started on opiates and was followed by pain management specialists for several years. However, the patient did not like how they felt on the medication and was tapered off. The patient stated that they have been using edible marijuana for pain control for several years but has continued to struggle with severe low back pain. The patient stated that the pain and discomfort has significantly impacted their ability to perform and complete their activities of daily living (ADLs). The patient endorsed pain in their lower back, occasionally radiating into their lower extremities. The patient noted that their last epidural injection caused severe vertigo that sent them to the hospital immediately after the procedure. The patient denies any bladder or bowel incontinence or focal weakness. The patient reported a 70 pound weight loss over the last several years. The patient indicates their pain level over the last week is ranging from 7-9/10.

The patient was seen for a follow up visit. The patient continues to have waxing and waning episodes of severe back pain. The patient reported axial pain with daily activities. The patient states their pain is worse with lumbar flexion, sitting, prolonged standing. Magnetic resonance imaging (MRI) of the lumbar spine demonstrates multi-level spondylosis or degenerative disc disease at L (lumbar) 4-5 and L5-S (sacral) 1 with endplate injury.

A radiologist reviewed the patient's MRI Lumbar spine which demonstrates Modic type 1 endplate edema at L3-L4 and Modic type II endplate fatty metaplasia at L4-L5 and L5-S1. Marked L4-L5 and L5-S1 disc degeneration was noted.

The scientific evidence in peer-reviewed literature support a result of improvement in health outcome. Recent literature has shown significant relief of pain that can be sustained at least 2 years.  

This patient is a good candidate for Intracept procedure to treat low back pain (procedure codes 64628 and 64629).

The proposed treatment is considered the best available treatment for this patient this time.

In summary, the denial of procedure to treat low back pain (procedure codes 64628 and 64629), to be provided, on a date to be determined and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.