Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Intracept procedure for intraosseous ablation of the basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging, first 2 vertebral bodies, lumbar or sacral

The insurer denied coverage for Intracept procedure for intraosseous ablation of the basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging, first 2 vertebral bodies, lumbar or sacral

The denial is upheld 

The medical records show the patient has a history of back pain with Modic changes. The patient underwent a lumbar epidural steroid injection for a diagnosis of lumbar radiculopathy. 

According to a prior authorization form the patient has "chronic low back pain (CLBP) due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplates changes frequently known by the eponym Modic on the magnetic resonance imaging (MRI)." The patient's back pain started over a year ago. The patient has been treated with Physical Therapy (PT), home exercise program, injections, sacroiliac joint injections and medications that include aspirin, Tylenol and non-steroidal anti-inflammatory drugs (NSAIDs). The patient's pain is reported to be affecting their activities of daily living (ADLs). A Magnetic Resonance Imaging (MRI) showed Modic changes in L (lumbar) 5 and S (sacral) 1. 

An office visit note reports the patient has not trialed Physical Therapy (PT); however, the patient does have a personal trainer and is losing weight while participating in a home exercise program. The patient has been taking Tylenol for greater than three (3) months and non-steroidal anti-inflammatory drugs (NSAIDs) for more than six (6) months. 

At this time, the provider is requesting approval for Intracept procedure for intraosseous ablation of the basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging, first 2 vertebral bodies, lumbar or sacral, which is the topic of this review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. While results may appear, promising additional studies are necessary to determine efficacy as compared to other conventional therapies. Medicare does not have a national coverage determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. 

64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral does not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral.     

There is not enough evidence to determine definitive conclusions concerning the clinical safety and efficacy of the requested procedure. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of Intracept procedure for intraosseous ablation of the basivertebral nerve, code 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging, first 2 vertebral bodies, lumbar or sacral and coverage for the requested service/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 not substantially increased over standard treatments.