Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Facet Arthropathy
Treatment: procedure code 22899, nerve treatment in the spine
The insurer denied coverage for procedure code 22899, nerve treatment in the spine
The denial is upheld

The patient has a history of chronic low back pain. She has had conservative treatment for at least six months and includes chiropractic care, Tylenol, non-steroidal anti-inflammatory drugs (NSAID), tizanidine, acupuncture, medial branch blocks with one week relief, another set with minimal relief, and an injection of the lumbosacral transitional vertebrae with good relief while standing. Her pain is worse with sitting and lying down. Her pain ranges from 5-7/10 and worse with activity. She has difficulty with activities of daily living. Her exam notes decreased range of motion and pain with extension and facet loading. A lumbar magnetic resonance imaging (MRI) evaluation stated at lumbar (L)4-5 grade 1 retrolisthesis of L4 on L5. Modic type I endplate changes and loss...signal and intervertebral disc height at L4-5. A circumferential disc bulge with superimposed central protruding disc herniation severely narrowed the spinal canal, thickening of ligamentum flavum and moderate facet arthrosis, moderate bilateral neural foraminal narrowing with abutment of the exiting L4 nerve roots. Her diagnoses listed Bertolotti's syndrome, lumbar facet arthropathy and vertebrogenic pain. The plan was for the Intracept procedure L4, L5 under fluoroscopic guidance.

There is evidence in peer reviewed literature that supports improvement in health outcomes for patients with vertebrogenic pain over 5 years.

The Intracept Intraosseous Nerve Ablation System is FDA (Food and Drug Administration) approved. The Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency (RF) generators for the ablation of basivertebral nerves of the L3 through S (sacral)1 vertebrae for the relief of chronic low back pain of at least 6 months duration that has not responded to at least six months of conservative care and is also accompanied by either Type 1 or Type 2 Modic changes on an MRI. The Intracept System technique uses RF ablation of the basivertebral nerve for relief of chronic low back pain and involves a two-step process.  First, utilizing the Instrument Set, a minimally invasive, "transpedicular approach" is used to allow the placement of a cannula into the vertebral body, and a path or channel is created to the terminus of the basivertebral foramen.  An RF Probe is then placed into this channel at the terminus of the basivertebral foramen, and controlled RF energy is delivered to destroy the basivertebral nerve where it enters the vertebral body.  This nerve has been identified as a proprioceptive sensory nerve with innervation of the vertebral endplates. (1)

The patient is not a good candidate for CPT 22899. She has severe central stenosis at L4-5 due to a herniated disc and a grade 1 retrolisthesis. She has significant disc height loss as well. It is unknown if just treating the basivertebral nerve is sufficient for her pain relief.

Given her lumbar pathology at the L4-5 level, CPT 22899 would not be the best available treatment for this patient at this time. Again, she has severe central stenosis and a retrolisthesis that may possibly be unstable. No flexion/extension x-rays were completed.

Literature does not support that the requested nerve treatment is likely to be more beneficial than any other standard procedure.

The carrier's denial of the procedure code 22899, nerve treatment in the spine should be upheld.