Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain. 
Treatment: Surgical procedure to treat low back pain (procedure codes 64628 and 64629). 
The insurer denied coverage for surgical procedure to treat low back pain (procedure codes 64628 and 64629). 
The denial is upheld. 

According to the medical records, the patient has chronic low back pain associated with degenerative disc disease. There are Modic changes in the magnetic resonance imaging (MRI). The medical provider states the patient's prior treatment includes activity modification, acupuncture, facet injections, bracing and multiple medications. Details regarding findings on examination include an absence of tenderness, slight decreased flexion and extension, no motor weakness. No details regarding reflexes are provided. A request for procedures using Current Procedural Terminology (CPT) codes 64628 - Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral; 64629 (1 unit)- Thermal destruction of intraosseous basivertebral nerve, inclusive of all imaging guidance, each additional vertebral body, lumbar or sacral was denied. 

Further investigation by higher powered studies are needed to establish the short-term and long-term efficacy of this treatment as it pertains to this patient's pain. 

Michalik, A., Conger, A., Smuck, M., Maus, T. P., & McCormick, Z. L. (2021), "Basivertebral nerve (BVN) radiofrequency ablation appears to be an effective treatment for a subset of patients with chronic low back pain (CLBP) and evidence of Modic change types 1 and 2 in the lumbar (L) 3 to sacral (S) 1 visual evoked potentials (VEPs) who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results." 

Francio, V.T., and Sayed, D. (2023), "Low back pain remains a global concern in healthcare. Diagnosing the source of low back pain remains a clinical challenge for healthcare providers, and often treatment interventions have a wide level of efficacy given poor specificity in the diagnosis. Among the hypothesized sources of low back pain, vertebral pain resulting from damaged vertebral endplates has gained attention with specific and reliable diagnostic criteria and several clinical studies reporting robust effectiveness data using intraosseous basivertebral nerve ablation as a targeted intervention in this subset of patients with low back pain of vertebral etiology."    

The procedure codes 64628 and 64629 do not have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for procedure codes 64628 and 64629. 

The procedure codes 64628 and 64629 is not the best available treatment for this patient at this time. 

As stated above there is no scientific evidence in peer-reviewed literature supporting improvement in health outcome after performing these procedures. 

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

In summary, the denial of a surgical procedure to treat low back pain, procedure codes 64628 and 64629, requested by Relievant Medsystems to be provided on a date yet to be determined 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 risk are substantially increased over standard treatments.