Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: lumbar radiculitis, left hip pain, cervical spondylosis, and failed back syndrome of the lumbar spine

Treatment: 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum

The insurer denied coverage for 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum.

The denial is upheld.

This adult female has a history of hypertension, hypercholesterolemia, hypothyroidism, coronary artery disease (CAD), sleep apnea, anemia, hip fracture, thalamic hemorrhage, vertebrogenic pain, cervical radiculitis, lumbar spondylosis, and degenerative disc disease (DDD). She presented to the Pain Management physician's office to discuss treatment options for vertebrogenic pain. The patient complained of lower back pain that was worse with movement. She had a laminectomy and a recent lumbar epidural steroid injection (LESI). She has worked with a physical therapist (PT) for several years. Pain continues to interfere with her ability to function and perform activities of daily living (ADLs). Back pain has failed conservative treatment for more than six months. The physician recommended scheduling the Intracept procedure for Modic changes noted at L (lumbar) 3, L4, and L5.

Fischgrund and colleagues (1) published a double-blind, sham controlled randomized controlled trial (RCT) evaluating the Intracept system and radiofrequency (RF) ablation of the basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85C for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Oswestry disability index (ODI) of 30 points (on 100-point scale) and a minimum visual analog scale (VAS) of 4 cm [centimeter] (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance. 

In sum, this is still an experimental/ investigational procedure. Both UpToDate (3) and Hayes technology assessment (4) consider this experimental/ investigational. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum should be upheld.