Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Pain management services/ablation, 2 units
The insurer denied coverage for pain management services/ablation, 2 units.
The denial is upheld.

This case involves a patient who is being recommended for the Intracept procedure to treat vertebrogenic low back pain.  A magnetic resonance imaging (MRI) of the lumbar (L) spine identifying spondylosis and facet arthrosis with a small right-sided disc protrusion at thoracic (T) 12- L1, new compared to a prior MRI.  There was also moderate right foraminal stenosis at L4-L5.  The patient was seen complaining of lower back pain and bilateral knee pain graded 10/10.  The patient endorsed multiple interventional therapies including physical therapy, hot/cold packs, lumbar epidural steroid injection, medial branch blocks, trigger point injections, and oral medications.  Comorbidities include a history of tobacco use, evidence of hypertension, and a history of alcohol abuse.  On physical examination, the patient's heart rate was elevated at 103 with elevated blood pressure at 177/105.  He had an elevated body mass index (BMI) of 31.17 and positive bilateral facet loading.  The patient was neurologically intact.  The report stated that the patient was being considered for a Viadisc procedure in addition to the Intracept procedure.  The treating physician was requesting prior authorization for intraosseous ablation of the basivertebral nerve (BVN), which was accomplished with the Intracept procedure.  The physician described that the patient's primary problem is chronic low back pain due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplate changes, frequently known as modic changes on MRI.  

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Pain management services/ablation, 2 units has final approval from the appropriate regulatory bodies for this diagnosis.

This patient a good candidate for pain management services/ablation, 2 units.

Pain management services/ablation, 2 units is one of the best available treatments for this patient at this time.

The adverse risks are not increased over standard treatment/services.

While the patient may be a suitable candidate for the Intracept procedure based upon the imaging evidence, subjective and objective findings on examination, and failure to respond to conservative measures, it was determined that because he was being considered for multiple treatment measures to include Viadisc procedure to treat his symptoms, proceeding with the Intracept would not be appropriate at this time. 
Furthermore, the patient was educated on weight loss and would need to get his blood pressure under control and have tachycardia addressed before proceeding with any invasive or semi-invasive treatment.  Given these findings, it was determined that denial of coverage for pain management services/ablation, 2 units is appropriate.  

In summary, the denial of pain management services/ablation, 2 units and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.