Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Low Back Pain

Treatment: 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral (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 request for Intracept procedure. Magnetic resonance imaging (MRI) of the lumbar spine noted post-laminectomy and fusion changes at lumbar (L)4-5 and L5-sacral (S)1 with spinal cord stimulators in place. The patient was noted to have type II Modic endplate changes at thoracic (T) 12-L1 with disc height loss and disc bulge compressing the thecal sac along with moderate central stenosis and mild bilateral foraminal stenosis. There were also faint type I Modic endplate changes at L3 -4 with disc height loss, disc bulge compressing thecal sac, moderate central stenosis, and moderate to severe bilateral foraminal stenosis. Clinical note reported the patient had complaints of low back pain radiating to the left lower extremity. Past treatment included epidural steroid injections, medial branch blocks, surgery, and spinal cord stimulation along with medication management. Physical examination noted lumbar paraspinal tenderness to palpation bilaterally, 65 degrees of flexion, 10 degrees of extension, intact sensation, and intact strength. Treatment plan was for MRI of the thoracic spine with consideration for Intracept procedure and epidural steroid injection. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) does have final approval from the appropriate regulatory bodies for this diagnosis.

Scientific literature supports patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in ODI (official disability index) and VAS (visual analog scale) and maintained high responder rates for years following treatment. Per the International Society for the Advancement of Spine Surgery guideline, intraosseous ablation of the basivertebral nerve from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain of at least 6 months duration when there is failure to respond to at least 6 months of nonsurgical management, and MRI d emonstrated Modic change 1 or Modic change 2 in at least 1 vertebral endplate at 1 or more levels from L3 to S1.

In this case, the patient has a history of chronic low back pain with failure of conservative care to include surgery, medication, physical therapy, injections, and spinal cord stimulation. The patient has radiologic findings of Modic type I and II endplate changes consistent with causing vertebrogenic pain.

The request for intracept procedure is likely to be more beneficial than any other treatment at this time. As such, the prior denial is overturned.

64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

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.