Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The insurer denied intraosseous basivertebral nerve ablation. 
The determination is upheld. 

This is a female patient diagnosed with low back pain. The records provided indicated the patient was recommended for the Intracept procedure. 
It was noted the patient has a history of low back pain that began many years ago. She has had multiple treatments including home exercise, medication management, physical therapy. Medications have included baclofen, gabapentin, Lyrica, medical marijuana, meloxicam, non-steroidal anti-inflammatory drugs (NSAIDs), over-the-counter medications, pregabalin, tramadol and Tylenol. The pain is impacting her activities of daily living and ability to work. Nothing has provided any sustained benefit. The provider noted she had magnetic resonance imaging (MRI) scan performed that demonstrated Modic changes at disc spaces lumbar (L) 3, L4, L5, and sacral (S) 1 and the provider believes is the source of the patient's chronic back pain. 
The patient was seen for a pain management consultation with complaints of chronic low back pain. It was noted that pain is across the low back and radiates to the bilateral hips and down all aspects of the thighs to the knees, exacerbated with activities. She reports intermittent numbness and tingling into the bilateral legs. She has tried multiple medications and has done physical therapy on and off for several months. She had a lumbar epidural injection years ago without relief. Current medications include Azelastine, baclofen, fluticasone, gabapentin, meloxicam, metformin, omeprazole, pregabalin, rosuvastatin, tramadol, triamterene-hydrochlorothiazide.  Intraosseous basivertebral nerve ablation (BVN) is under review. 
The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The patient was noted have complaints of chronic back pain radiating into the lower extremities down the thighs to the knees with intermittent numbness and tingling in the bilateral legs that would be considered more consistent with radiculopathy rather than vertebrogenic pain. The provider states that the patient had an MRI showing Modic changes at disc spaces L3, L4, L5 and S1; however, the MRI report submitted for review did not document this from the radiologist perspective. There was no mention of degenerative endplate changes or Modic changes. There are a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment.