Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: procedure to treat low back pain (procedure code 64628)

The insurer denied coverage for procedure to treat low back pain (procedure code 64628)

The denial is overturned

This case involves an adult diagnosed with vertebral genic low back pain, low back pain, vertebral endplate pain, and spondylosis without myelopathy or radiculopathy of the lumbar region who was being recommended for the Intracept procedure.  The documentation provided for the review included a magnetic resonance imaging (MRI) report which noted lumbar (L)2-3 to L4-5 posterior annular disc bulges deforming the ventral thecal sac with right foraminal extension at L3-L4 below the level of the exiting nerve root.  At L5- sacral (S)1, there was broad-based central disc herniation deforming the ventral epidural space and impinging upon the traversing S1 nerve roots.  There is left foraminal extension abutting the exiting left L5 nerve root with facet hypertrophic changes.  Additional findings include a curvature of the lumbar spine convexity to the right.  The patient had complained of low back pain.  Prior relevant treatment included support bracing, anti-inflammatories, chiropractic care, acupuncture, epidural steroid injections, facet joint injections, and sacroiliac joint injections.  The patient admitted to persistent axial back pain, worse with bending forward.  Symptoms were improved with standing and worsened with sitting.  She displayed symptoms of anterior column low back pain and modic changes on MRI. 

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

This procedure to treat low back pain (procedure code 64628) has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for the procedure to treat low back pain (procedure code 64628).

This procedure to treat low back pain (procedure code 64628) is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

Given the patient's limited response from prior conservative measures and some invasive measures of treating low back pain, it was concluded that the requested service is likely to be more beneficial than any of the standard treatment/procedures for this patient.

Her MRI report identified Modic changes in the lumbar region.  She was therefore deemed to be a suitable candidate for proceeding with the Intracept procedure.  After a review of the provided documentation and in reference to current evidence-based literature, it was determined that the patient meets the criteria for pursuing the Intracept procedure to treat her chronic low back pain.  As such, the Intracept procedure (procedure code 64628) to treat low back pain is medically necessary.

In summary, the denial of procedure to treat low back pain (procedure code 64628) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.