Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative disc disease

Treatment: Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation)

The insurer denied coverage for Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation).

The denial is overturned.

According to the clinical documentation provided for review, the patient is a male. The patient presented with chronic low back pain. The patient underwent magnetic resonance imaging (MRI) studies which showed modic changes affecting the endplates. The patient had previously undergone a laminectomy and discectomy apparently at the lumbar (L) 5 to sacral (S) 1 level. The patient's back pain has been treated with exercises. The patient has had a Medrol Dosepak. On examination (exam) the patient is comfortable while standing and walking. Extension causes some discomfort in the low back. Flexion causes increased pain. The patient has no neurological deficit. It has been recommended that he undergo a basi-vertebral nerve procedure. The radiographic imaging (X-rays) of the lumbar spine shows no acute osseous abnormality and mild lower lumbar spine degenerative changes. The MRI of the lumbar spine showed Schmorl node indenting the inferior body of L5. A prior large disc fragment had been removed. The treating provider is requesting plan approval for treatment with pain Management, outpatient (OP) procedure, 64628, x 1, intraosseous nerve ablation.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. "Chronic low back pain affects a significant portion of patients worldwide and is a major contributor to patient disability; however, it is a difficult problem to diagnose and treat. The prevailing model of chronic low back pain has presumed to follow a discogenic model, but recent studies have shown a vertebrogenic model that involves the basivertebral nerve (BVN). Radiofrequency ablation of the BVN has emerged as a possible nonsurgical therapy for vertebrogenic low back pain." (Urits, et al, 2021)

"Basivertebral nerve (BVN) ablation is a minimally invasive spinal procedure targeting the BVN, which is responsible for carrying nociceptive information from damaged vertebral endplates, an entity recently postulated as a source of chronic axial low back pain (LBP)." (Tieppo, et al, 2022)

"Patients treated with RF (radiofrequency) ablation of the BVN for CLBP (chronic lower back pain) exhibited significantly greater improvement in ODI (Oswestry Disability Index) at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain. These slides can be retrieved under Electronic Supplementary Material." (Fischgrund, J. S., et al, 2018)

Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation) is Food and Drug Administration (FDA) approved.

The patient is a good candidate for pain management outpatient procedure, 64628, x 1, intraosseous nerve ablation, based upon reasons provided by the provider, as well as support from medical literature. 

Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation) is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services. This patient has already failed appropriate conservative measures for the treatment of his chronic low back pain and further management is needed at this time.

Based upon all information provided above, the requested service is likely to be more beneficial than any of the standard treatment procedures for this patient. This patient has continued low back pain, in spite of other therapies tried. He has failed appropriate conservative measures for the treatment of his chronic low back pain and is in need of ongoing management. 

In summary, the denial of Pain Management outpatient procedure (64628 x 1) (Intraosseous Nerve Ablation) should be overturned.