Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied INTRACEPT procedure. 
The denial was upheld in whole.

The patient is a female with low back pain and lumbar degenerative disc disease noted on magnetic resonance imaging (MRI); Intercept Procedure is proposed.
The patient has had past treatment with epidural steroid injection, lumbar medical branch blocks, physical therapy, transcutaneous electrical nerve stimulation (TENS), core strengthening exercise with Pilates and medications.

The Intercept procedure is proposed for suspected discogenic pain.

The health plan's determination is upheld.

The proposed Intercept Procedure is not likely to be more beneficial.
A prospective case series and review of literature of basivertebral and sinuvertebral nerve ablation states (in part), "A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain" [1]. The case series and review of literature is limited to a small number of subjects.
A guideline issued by the International Society for the Advancement of Spine Surgery Guideline on intraosseous ablation of the basivertebral nerve (BVN) for the relief of chronic low back pain concludes (in part), "Intraosseous ablation of the BVN is a relatively new minimally invasive treatment for the relief of chronic low back pain (CLBP) that is diagnosed using well-established clinical and MRI findings. The procedure is supported by level 1 evidence including 2 randomized controlled trials (RCTs) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies" [2]. Multiple limitations of the guideline are present. 
The current standard of care is summarized in a Clinical Practice Guideline from the American College of Physicians on the Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain [4]:
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)".
In short, reliable evidence shows that the consensus among qualified objective experts is that further clinical studies, are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment.