Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

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

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

The denial is upheld 

Reviewer #1:

This patient has chronic low back pain. The patient has tried Mobic and opioids, Physical Therapy, Chiropractic, and acupuncture. The request is for radiofrequency ablation (RFA) of the basivertebral nerves (BVN) of L (lumbar) 3, L4, L5 and S (sacral) 1. The magnetic resonance imaging (MRI) report stated L3-L4 "large posterior disc protrusion...contacting the right L4 nerve root.  L4-L5 moderate-severe bilateral neural foraminal stenosis with impingement  of the existing L4 nerve roots. L5-S1 broad based posterior disc herniation...moderate bilateral neural foraminal stenosis." The impression was "...multilevel spondylosis preferentially effecting the lower motion segments." The report concludes Modic 1 for L3-4. There is no mention of Modic changes for other segments.

In 2018, Fischgrund and colleagues (1) published a double-blind, sham-controlled randomized controlled trial (RCT) evaluating the Intracept system and radiofrequency (RF) ablation of the basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85Celsius for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Oswestry disability index (ODI) of 30 points (on 100 point scale) and a minimum visual analog scale (VAS) of 4 centimeters (cm) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13%) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

Urits et al (6) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care. In addition the MRI report notes the presence of findings that were an exclusion in the randomized studies  (Khalil et al).

In summary, the denial of procedure to treat low back pain (procedure codes 64628 and 64629), to be provided on a date 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 risks are substantially increased over standard treatments.