Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 55-year-old male insured has requested authorization and coverage for thermal destruction of 
the intraosseous basivertebral nerve, including the first two vertebral bodies, lumbar or sacral, 
Intracept procedure (CPT 64628). The Health Insurer has denied this request indicating that the 
requested services are considered investigational for the treatment of the insureds chronic back 
pain. The physician reviewer found that this patient presents with a history of chronic back pain. 
The  patients  provider  has  recommended  basivertebral  nerve  ablation  with  the  Intracept 
procedure, which is a promising minimally invasive treatment option for patients with isolated 
vertebrogenic pain. As noted in the medical literature, good therapeutic results can be achieved 
through proper patient selection. The current peer-reviewed medical literature includes clinical 
studies reporting on patients with isolated lumbar back pain as the chief complaint for treatment. 
However, the current randomized controlled studies included patients with isolated lumbar back 
pain as the chief complaint, with exclusion criteria specified in the studies in order to avoid 
overlapping  pain  sources.  Among  these  exclusions  is  the  presence  of  other  concomitant 
symptoms or painful radiographic findings related to spine pathology that would overlap the 
vertebrogenic pain pattern and would obscure the clinical presentation. Thus, making it difficult 
to isolate vertebrogenic pain as the main problem to be treated. Patients with those findings 
were excluded from the studies as it would not be guaranteed that the Intracept procedure can 
be beneficial. This patient complains of low back pain that has persisted for longer than six  months and has not responded to conservative measures. He also has Modic changes noted on 
the MRI at L5-S1 which may point towards some vertebrogenic type pain origin. However, he 
does have overlapping clinical symptoms and other imaging findings that are more significant 
and potentially more pronounced sources of pain. The providers notes dated 2/15/23 state that 
the patient has back pain, bilateral thigh numbness, and heaviness, which is improved with 
flexing forward and is indicative of lumbar claudication due to spinal canal stenosis. This also 
correlates with the MRI findings which showed L4-5 and L5-S1 ligamentum flavum hypertrophy 
and stenosis both central and foraminal stenosis. Also noted was grade 1 anterolisthesis at L5-S1 
with loss of disc space, facet arthropathy, and hypertrophic overgrowth. These findings represent 
overlapping pain sources that have been considered exclusion criteria from the published studies 
on the efficacy of the Intracept procedure. Furthermore, the epidural steroid injection that the 
patient received on 12/15/22 provided relief for three weeks, further confirming that spinal 
stenosis and ligamentum hypertrophy are likely the main causes of the patients symptoms. 
Given that the published studies do not apply to this patients clinical setting with documentation 
of multiple exclusion criteria, the requested Intracept procedure is not likely to yield a superior 
health outcome when compared to standard available treatment modalities. Therefore, the 
requested thermal destruction of the intraosseous basivertebral nerve, including the first two 
vertebral bodies, lumbar or sacral, Intracept procedure (CPT 64628) is not likely to be more 
beneficial for the treatment of the patients medical condition than any available standard 
therapy.