Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve thermal destruction of intraosseous basivertebral nerve, including 
all imaging guidance; first 2 vertebral bodies, lumbar or sacral and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first 2 vertebral bodies, lumbar or sacral and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. You say 
that the requested services are medically necessary. The Plan denied your request. The Plan says that the 
requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and thermal 
destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, 
lumbar or sacral. Our reviewer says that the requested thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and thermal destruction of 
intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or 
sacral are considered medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee is a 58-year-old female who has chronic back pain for many years with degenerative disc disease, 
limiting function and having failed conservative treatment. Based on the currently available evidence to support 
the use of this procedure for those with chronic low back pain, this procedure appears appropriate, likely to be 
effective for at least short-term and potentially longer-term relief, and not experimental. Therefore, this request 
will be considered medically necessary for the enrollees condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral and thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; each additional vertebral body, lumbar or sacral have been met. Therefore, we 
decided that the Plan has to pre-approve thermal destruction of intraosseous basivertebral nerve, including all 
imaging guidance; first 2 vertebral bodies, lumbar or sacral and thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.