Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar (L) or sacral (S) (Intracept).
The insurer denied coverage for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral (Intracept).
The denial is overturned

This case involves a patient diagnosed with chronic back pain who is being considered for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral (Intracept).  The patient reported sharp back pain with radiation down the bilateral lower extremities.  His symptoms increase with sitting, standing, walking, and bearing down.  He reportedly failed conservative measures had diagnostic imaging evidence showing multilevel degenerative disc disease, spinal canal stenosis and neuroforaminal narrowing.  There is a circumferential disc bulge eccentric to the right L3-L4 effacing the right lateral recess and abutting the descending right L4 nerve root.  He also had left paracentral disc bulging at L4-L5 effacing the left lateral recess and compressing the descending left L5 nerve root with no cord compression or abnormal cord signal.  The patient received a notice of adverse determination stating that the treatment had not been shown to be effective for the patient's condition.  It was also indicated that medical scientific studies were incomplete with studies in the small numbers of patients

Scientific evidence in peer reviewed literature supports the results of improvement in health outcomes.

The Intracept does not need final approval from the appropriate regulatory bodies for this diagnosis.  The FDA (Food and Drug Administration) has already approved this treatment.

The patient is a good candidate for Intracept.

The Intracept is considered the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services. This procedure is likely to be more beneficial than any other standard services.

Literature has noted that degenerative lumbar spine disorder (DLSD) is a ubiquitously occurring event that may be induced or accelerated by multiple factors such as from overuse, trauma, genetic predisposition, nutrition deficiency, and others.  Additionally, vertebral endplates, innervated by the basivertebral nerve, can be a source of vertebrogenic low back pain when damaged with inflammation, visible as types 1 or 2 Modic changes.  Evidence has found that interosseous basivertebral nerve ablation (BVNA) demonstrates an excellent safety profile and significant improvements in pain, function, and quality of life that can be sustained for up to 24 months and patients with chronic vertebral genic low back pain.  In the case of this patient, records noted that he had abnormal findings on diagnostic imaging and failed to respond to conservative measures with medications, caudal epidural steroid injections, lumbar epidural steroid injections, medication management, and radiofrequency ablations.  It was therefore determined that given the evidence within current medical literature that the proposed treatment would likely to be more beneficial that any of the standard treatments/procedures to address the patient's symptoms.  

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) should be overturned.