Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lower back pain

Treatment: Service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum

The insurer denied coverage for service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum.

The denial is overturned.

This is a male patient who has a history of hypertension, benign prostatic hypertrophy (BPH), bilateral lower extremities lymphedema, hypercholesterolemia, anxiety, and chronic low back pain. He was under the care of a pain management physician for complaints of lower back pain. The pain was aggravated by activity. The patient had consultations with physical therapists, a neurologist, and a chiropractor. He has received injections, physical therapy, acupunctures, and home stretching. The patient was on Norco, Valium, and methocarbamol medications. There was no significant relief on all of the medications. Magnetic resonance imaging (MRI) of the lumbar spine revealed mild superior lumbar vertebrae (L) 2 endplate deformity, consistent with a chronic injury, minimal posterior bulging disc annulus, L1-2 with mild bilateral facet arthropathy, very small central and left lateral disc herniation, L2-3 with mild bilateral facet arthropathy and minimal reverse spondylolisthesis, mild left L3 root origin compression, minimal posterior bulging disc annulus, L3-4 with mild to moderate bilateral facet arthropathy, very mild thecal sac deformity, mild to moderate central broad-based disc herniation/ridge, L4-5 with mild degenerative disc narrowing and moderate bilateral facet arthropathy, mild thecal sac deformity and moderate bilateral L5 root origin compression, slightly more left-sided, moderate bilateral foraminal narrowing is present, right greater than left and subcortical marrow findings at the degenerated L4-L5 level are predominantly thoracic vertebrae (T) 1 and T2 hyper-intense, consistent with Modic type II changes.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Studies have shown high responder rates with sustained clinical improvement in function and pain for 6.4 years on average. The procedure has the support of the International Society for the Advancement of Spine Surgery and is noted to have Level I evidence including 2 randomly controlled trials demonstrating a statistically significant decrease in pain and improvement in function with outcomes sustained for at least 24 hours. Service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum does have final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the procedure. Clinical indications include axial lower back pain with over 6 months duration and failure to respond to at least 6 months of conservative measures and a magnetic resonance imaging (MRI) showing Modic Type 1 or 2 changes in at least one vertebral endplate between L3 to S1 (sacral vertebrae 1). The patient does have chronic pain despite treatment and MRI demonstrates L4-5 Modic Type II changes.

This procedure is likely to be more beneficial than any other standard treatments or procedures. There is evidence to support use of this procedure with sustained benefit versus surgical intervention or continued medication use as noted in clinical studies.                                                      

The carrier's denial of coverage for service code 22899 unlisted procedure, spine (Intracept Procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum should be overturned.