Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbosacral Degenerative Disc Disease
Treatment: Intracept Procedure
The health plan denied the Intracept Procedure
The determination is upheld.


The patient has a diagnosis of chronic low back pain present for many years that progressively worsened. It was noted the patient's back pain is affecting activities of daily living and pain is aggravated with standing and prolonged sitting. The pain is rated at 6/10. Prior conservative treatment has included physical therapy, a home exercise program, stretching, medications (Celebrex), transforaminal epidural steroid injection, sacroiliac (SI) joint injections with temporary relief. It was noted in the case notes that magnetic resonance imaging (MRI) of the lumbar spine  revealed Modic type I changes at lumbar (L) 5-sacral (S) 1 disk space. The treating provider recommended that the patient undergo the Intracept Intraosseous basivertebral nerve ablation procedure.
The patient was noted to have complaints of low back and bilateral leg pain with tingling in the feet, throbbing pain with stiffness in the low back with occasional sharp pain in the posterior legs and associated tingling, pins and needles, primarily in both feet. It was noted the patient performs stretches and physical therapy exercises. The physical examination revealed limited lumbar range of motion. Kemp's test on the right was productive of contralateral low back pain. Sacral compression produced a low back ache. The lower extremity sensory exam was intact. Achilles reflexes were trace on the right with distraction and 1 on the left with distraction. Motor strength was decreased at 4/5 to the bilateral extensor hallucis longus (EHL). Straight leg raise testing was positive bilaterally at 70-75. It was noted that the patient would be scheduled for bilateral S1 transforaminal epidural steroid injection, be started on a trial of Celebrex for anti-inflammatory/pain relief, and if conservative treatment fails, the patient would be recommended for Intracept procedure at L5 and S1.
At issue is whether the Intracept Procedure: Intraosseous Basivertebral Nerve Ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The proposed health service or treatment Intracept Procedure: Intraosseous Basivertebral Nerve Ablation 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 is noted to have a history of chronic back pain with radicular symptoms, objective findings of radiculopathy and corroborative findings of radiculopathy on MRI to include multilevel disc herniations at L4-L5 and L5-S1. There is no evidence to suggest vertebrogenic pain over that of pain related to the disc herniations. There were no detailed progress notes indicating the patient to have failed other treatments such as nonsteroidal anti-inflammatory drugs, adjuvant neuropathic medications such as antidepressants or anticonvulsants, or failed epidural injections. There is no evidence to support the Intracept procedure as resulting in improvement in health outcomes, particularly over that of standard surgical options such as discectomy/fusion. There are a lack of high-quality long-term studies showing this treatment to be as effective or more effective than that of standard means of treatment for this condition and further long-term studies are needed to establish the overall safety and efficacy of this treatment. There is no evidence to suggest this treatment would be as beneficial or more beneficial than other standard treatments for this patient's condition.

The determination is upheld.