Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The insurer denied coverage for procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is upheld.

This is an adult with a history of lumbago, lumbar radiculopathy, lumbar spondylosis, carpal tunnel syndrome, and vertigo. The patient presented to the Pain Management physician's office for a follow up for back pain. Pain was rated at a 7-9 out of 10. The patient has tried and failed physical therapy (PT), injections, lidocaine patches, prednisone, and naproxen without relief. Imaging revealed mildly progressed multilevel degenerative disc of the lumbar spine, mildly increased paraspinal muscle atrophy. The physician recommended the Intracept procedure to treat back pain. 

There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. As such, at this time the Intracept procedure is experimental/investigational.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. The procedure has Food and Drug Administration (FDA) approval for marketing. There are no guidelines nor statements about efficacy. 

This patient is not a good candidate for procedure codes 64628 and 64629. The records show no distinct pain generator has been defined. The patient has global spine pain. Her physical examination showed pain localized to several different sites. She has been reported to have pain to the disc, facet, and sacroiliac (SI) joint. She has been reported to have instability patterns and stenosis to her spine. She has imaging studies which show multilevel degenerative changes. She has undergone a multitude of treatments with some reported transient benefit. These include medial branch block (MBB), radio frequency ablation (RFA), and epidural steroid injection (ESI) injections. 

Simply stated, an isolated intraosseous nerve ablation is not likely to change her course. There is no medical documentation to confirm the single vertebral body causing her problem. Nevertheless, the procedure by itself is not standard of care nor recognized by the majority of the practicing medical community. It is not found to be efficacious by any Orthopedic or Neurosurgical Association. The requested procedure is not the best available treatment for this patient at this time. It is invasive and there can be problems with instrumentation and infection. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are possibly increased over standard treatments. 

The insurer's denial of coverage for procedure code 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and procedure code 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (list separately in addition to code for primary procedure) is upheld.