Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain
Treatment: Intraosseous basivertebral nerve ablation [CPT (Current Procedural Terminology) code 64628 and 64629]
The insurer denied coverage for intraosseous basivertebral nerve ablation (CPT code 64628 and 64629).
The denial is upheld.

This is a patient with chronic radiating back pain and occasional foot numbness. Prior treatment included chiropractic, physical therapy, epidural steroid injections and analgesic medications. Currently under review is the medical necessity of requested Intracept procedure (intraosseous basivertebral nerve ablation - CPT code 64628 and 64629). 

Patients who are amenable to this procedure have non-radiating (axial) pain. In this particular case and documented in the treatment note from nurse practitioner, the patient presented with "chronic low back pain and radiating leg pain" as well as "associated numbness in the feet that is intermittent," which are consistent with his primary listed diagnosis of "Lumbar radiculopathy" and not consistent with basivertebral nerve (BVN) etiology. Magnetic resonance imaging (MRI) scan also documented evidence of multilevel degenerative disc disease and associated nerve root impingement; again consistent with a radiculopathy. 

The Intracept procedure is Basivertebral nerve (BVN) ablation. The BVN carries nociceptive information from damaged vertebral endplates, an entity recently postulated as a source of chronic axial low back pain (LBP). There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria utilized in the published literature to date (1,2,3,4) . The published peer review studies are usually hampered by small sample size, limited long term results and often industry funded. However, success is often correlated with appropriately selected subjects. 

In this particular case, the patient's presentation (chronic lumbar radiculopathy with documented multilevel degenerative disc disease and associated nerve root impingement) render him an unlikely candidate or benefit from the requested procedure. The requested Intracept procedure (intraosseous basivertebral nerve ablation; CPT code 64628 and 64629) should not be considered more beneficial than standard care.

The scientific evidence in peer-reviewed literature for intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) supports a result of improvement in health outcome for appropriate patients.

Intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) does not have final approval from the appropriate regulatory bodies for this diagnosis of chronic lumbar radiculopathy.

Based on the clinical records which document chronic lumbar radiculopathy with underlying radiological evidence of multilevel degenerative disc disease and associated nerve root impingement; This patient is not a good candidate for intraosseous basivertebral nerve ablation (CPT code 64628 and 64629).

This patient has well documented chronic lumbar radiculopathy; intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) is not the best available treatment at this time.

Risks of intraosseous basivertebral nerve ablation (CPT code 64628 and 64629); compared to non-spinal interventional treatment includes infection, hemorrhage and nerve damage. 

The requested treatment (intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) is unlikely to be more beneficial than any of the standard treatments/procedures for this particular patient with chronic lumbar radiculopathy.

In summary, the denial of intraosseous basivertebral nerve ablation (CPT code 64628 and 64629) 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 risks are substantially increased over standard treatments.