Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain. 
Treatment: Spine procedure (INTRACEPT) (C9752 & 22899). 

The insurer denied the Spine procedure (INTRACEPT) (C9752 & 22899).  The denial is upheld. 

The patient is a female with a history of chronic low back pain. She has failed MBBs (medial branch blocks) and RFA (radiofrequency ablation). She has done physical therapy and has tried various medications, including opiates. Her physical exam shows tenderness on palpation. An Intracept procedure has been recommended. The procedure was denied as experimental/investigational. This was appealed. 

No, the health plan should not cover the Intracept procedure. 

The patient is a female with a history of chronic low back pain. She has failed MBBs (medial branch blocks) and RFA (radiofrequency ablation). She has done physical therapy and has tried various medications, including opiates. Physical exam shows tenderness on palpation. An Intracept procedure has been recommended. 

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (United States Food and Drug Administration)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose. 

However, despite the above, this patient has not failed or attempted sacro-iliac joint interventions, which is a common cause of axial low back pain. The patient's pain is axial; there is notation of facet arthropathy on the MRI (magnetic resonance imaging). Modic changes can be present in no vertebrogenic back pain, which are not noted on the MRI (magnetic resonance imaging). In addition, no recent imaging is available, the last MRI (magnetic resonance imaging) was from approximately two years prior. 

Therefore, while the Intracept procedure is an FDA (United States Food and Drug Administration) approved procedure that is not experimental/investigational, and is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. SI (sacroiliac) joint interventions have been shown to be effective in low back pain. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate. 

No, the Intracept procedure is not more beneficial.