Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that intraosseous 
ablation of the basivertebral nerve is medically necessary. The Plan denied your request. The Plan says 
intraosseous ablation of the basivertebral nerve is unproven and not medically necessary and not covered by 
Medicare due to insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested intraosseous ablation of the basivertebral nerve is not 
considered medically reasonable and necessary. Our physician reviewer found this 68-year-old was being 
treated for vertebrogenic low back pain. The enrollee presented with chronic low back pain for over 5 years 
with a history of a lumbar fusion at L4-5. The enrollees computed tomography (CT) scan showed complete 
fusion of the L4-5 level, trace anterolisthesis of L2 on L3. The exam reveals a flexed antalgic gait with a 
single-point cane. The enrollee is unable to heel or toe stand. There is moderate tenderness to palpation in the 
paraspinal musculature of the lumbar spine on the righthand side from the upper lumbar spine extending down and lateral to her right hip. Strength and sensation are intact. The bilateral patellar and Achilles tendon reflexes 
are 1+. However, detailed documentation is not evident regarding Modic changes being corroborated by the CT 
scan at the requested intracept level. Additionally, there were/are multiple plausible pathologic sources of 
significant pain generation. The chronic back pain, prior fusion/trace anterolisthesis, the moderate tenderness to 
palpation (with an intact neurologic exam) were/are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. The 
documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
intracept intraosseous basivertebral nerve ablation at the L3 vertebral body in this case is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.