Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Pain. 

Treatment: 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum. 

The insurer denied coverage for 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum. 

The denial is upheld. 

The patient has a history of low back pain, vertebrogenic pain, lumbar spondylosis, lumbar facet arthropathy, and sacroiliac joint dysfunction of both sides. She has a prior bilateral laminectomy/foraminotomy at L (Lumbar) 4-5 and right intertrochanteric nailing. She has been treating with Pain Management and conservative treatments have included bilateral steroid injections with excellent relief for three months, a caudal epidural steroid L4-5 with excellent relief for 5 months and then 30% (percent) relief with a second one, and bilateral L3-L5 medial branch blocks with 80-100% relief. Her pain is in the low back and worse with sitting and walking. Her lumbar Magnetic Resonance Imaging (MRI) shows 75% disc space reduction at L4-5, Modic type I degenerative changes of the endplates at L4-5. L3-4 minimal bilateral compression of the exiting nerve roots, L4-5 with left paracentral disc extrusion causing moderate spinal canal stenosis and nerve root compression left greater than right due to foraminal stenosis with fluid in the facet joints. A lumbar MRI notes a grade 1 retrolisthesis at L4-5 with disc herniation with impingement of the left and right L5 nerve root, loss of disc space height, prominent nonspecific bone marrow signal changes within the endplates. L3-4 disc herniation abutting the L4 nerve roots with bilateral neural foraminal extension abutting the L3 nerve roots, loss of disc height. 

The Intracept Intraosseous Nerve Ablation System is food and drug administration (FDA) 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. 

The patient is not a good candidate for CPT 22899. She has a herniated disc, central and foraminal stenosis, severe loss of disc height and a grade 1 retrolisthesis at L4-5 with history of prior surgery that could be causing her symptoms. Furthermore, the Intracept procedure is not studied on prior performed surgical levels. 

The requested Intracept procedure is not likely to be more beneficial than any of the standard treatments/procedures for this patient. SThe adverse risks are not increased. he has significant pathology at the L3-4 and L4-5 levels that will most likely not respond to this procedure. 

The carrier's denial of 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum should be upheld.