Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

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

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

The denial is upheld.

According to the medical records, the patient is an adult female with chronic history of low back pain that began more than five (5) years ago. The patient has had the following treatments: caudal epidural steroid injections, injections, lumbar epidural steroid injections, medial branch block injections, medication management, physical therapy, sacroiliac joint injections and trigger point injections. The letter also stated that the patient's pain has had a significant impact upon activities of daily living (ADLs) and nothing has provided significant sustainable relief. The patient's condition has been characterized by a visual analog scale (VAS) score between 3/10 and 10/10. The letter also stated that the patient had a magnetic resonance imaging (MRI) performed a year ago, that demonstrated Modic changes. The request is for CPT (current procedural terminology) codes 64628 and 64629, which is under review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes. 

At this time the Intracept procedure remains as a procedure without established efficacy. While results may appear promising, additional studies are necessary to determine efficacy as compared to other conventional therapies. Medicare does not have a national coverage determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. 

64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral does not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral.     

64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral is not the best available treatment for this patient at this time.     

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

In summary, the denial of procedure to treat low back pain (CPT codes 64628 and 64629) and coverage for the requested service/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.