Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Neck and Low Back Pain. 

Treatment: 64628 (thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 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]). 

The insurer denied coverage for 64628 (thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 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]). 

The denial is upheld. 

The patient has a history of lower back pain. The patient had a follow up with a physician for chronic neck and low back pain, status post bilateral lumbar (L) 4-L5, L5 - sacral (S) 1 facet joint radiofrequency ablation (RFA). The patient reported 50% (percent) relief but continued to have axial lower back pain with flexion and prolonged activities. The patient had a magnetic resonance imaging (MRI) of the lumbar spine performed; the findings showed multilevel degenerative disc disease, spinal canal stenosis, and neural foraminal narrowing. Reciprocal type I Modic change at L3/4. The physician recommended the Intracept procedure for Modic changes noted at L3, L4, L5 for vertebrogenic pain. 

Per Tieppo et al. (2022), "The cumulative data among multiple studies on BVN (basivertebral) ablation demonstrated consistent, reproducible, clinically meaningful, and statistically significant improvement in reducing pain and improving function in patients with diagnostic evidence of vertebral pain. Among 11 clinical studies with direct patient data, 3 reviews, 2 clinical guidelines, and 1 systematic review published to date, there is a consensus that the procedure is effective at short-term and perhaps long-term in patients that meet the above-described indications." 

Conger et al. (2021) states, "There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN." 

Based on current and scientific evidence in peer-reviewed literature there is support of a result of improvement in health outcome for patients experiencing vertebral pain. 

This patient may be a good candidate for the requested procedures. However, there is no evidence the patient has recently been evaluated from an orthopedic standpoint since recent. Additional information is needed in the form of positive clinical evidence revealed on a recent orthopedic examination. Such documentation may include a diminished range of motion, diminished muscle strength, decrease in sensation, positive provocative testing, etc. Potential risks for a procedure are infection, postoperative pain, residual symptoms, and nerve damage. 

In summary, the denial of 64628 (thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 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]) and coverage for the requested treatment 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.