Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain

Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and
64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (Intracept)

The insurer denied coverage for Intracept procedure

The denial is overturned.

This case involves an adult with a history of low back pain who was being recommended for the Intracept procedure. Records stated that 3D magnetic resonance imaging (MRI) noted interval large disc extrusion at L2-L3 (lumbar 2-lumbar3) resulting in severe central canal stenosis with compression of the right L3 nerve roots. Progress notes reported the patient presented with chronic low back pain who previously received a left L1-L2 and L2-L3 transforaminal epidural steroid injection under fluoroscopic guidance with excellent relief for 2 weeks whereupon pain spontaneously returned. At the time of the visit, the patient was being recommended for an additional lumbar epidural steroid injection. During a follow up, the patient presented for neck and back pain with the low back pain most severe and present across the bilateral left greater than right region. The pain remained axial with improvement in leg and groin pain with previous lumbar epidural steroid injection. The patient had a history of L2-L3 microdiscectomy followed by middle branch block injections, facet injections, and lumbar epidural steroid injections. Exam findings noted stable vital signs with pain range between 6-8/10 occurring chronically in the left lower back. The physician had recommended thermal destruction of intraosseous basivertebral nerves, with the request denied with claims that the surgery was considered experimental and investigational.  

Current medical literature has noted that the Intracept procedure is a treatment for patients suffering from chronic low back pain from endplate disruption, utilizing basivertebral nerve radiofrequency ablation. This procedure has been found to be safe and effective in treating patients and was approved in April 2016. Given the findings within the clinical documentation, it was determined that the patient was a suitable candidate for proceeding with the Intracept procedure. The patient was having axial low back pain that responded temporarily to injections. Given that the proposed procedure has demonstrated consistent, statistically significant, and clinically meaningful, and durable improvement in pain, proceeding with the procedure as warranted.

The requested procedure is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.

The carrier's denial of 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) and
64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (Intracept) should be overturned.