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 who was diagnosed with lumbar disc displacement, lumbar radiculopathy, and lumbar degenerative disc disease.
A magnetic resonance imaging (MRI) of the lumbar spine (non-contrast) revealed Modic type 1 edematous endplate changes at L1-L2, L2-L3, and L5-S1; multilevel degenerative disc disease changes, and facet arthropathy resulting in varying degrees of the spinal canal and neural foraminal encroachment.
The progress note by the pain medicine provider indicated that the patient had a recent fall incident and hurt her ankle and back. It was indicated that the patient had three epidural steroid injections which helped her pain. The patient had no pain complaints for several months, however, her pain progressively worsened. The patient complained of constant back pain, which was worst in the morning. The pain was exacerbated by prolonged sitting/standing and was relieved by position changes and transcutaneous electrical nerve stimulation (TENS) unit. Other treatments the patient had tried included Pilates, physical therapy, home exercises, and pharmacotherapy (Oxycodone 5 milligrams [mg] as needed [PRN] for severe pain with good effect; and Tylenol with good effect). Pertinent physical examination findings included painful lumbar extension, positive facet loading, sacroiliac joint tenderness, 4-5/5 lower extremity strength, slightly diminished ankle jerk bilaterally, and negative straight leg raise test. The treatment plan was to proceed with bilateral facet intra-articular/medial branch block at L2-L3, L3-L4, L4-L5, and L5-S1 and to consider radiofrequency ablation (RFA). The subject under review is whether the proposed INTRACEPT procedure is likely to be more beneficial for this patient than standard treatment.

The health plan's determination is overturned.

The proposed treatment Intracept procedure is likely to be more beneficial than any standard treatments for the insured's disabling condition. The patient has chronic low back pain with features consistent with Type 1 Modic changes on the MRI, specifically, from L3-S1. Previous attempts at treatment have included epidural steroid injections X 3 with transient relief, Pilates, physical therapy, home exercises, and pharmacotherapy (Oxycodone 5 mg PRN for severe pain with good effect; and Tylenol with good effect). The patient had no pain complaints for several months, however, her pain progressively worsened. She reportedly had a fall incident where she hurt her ankle and back. The patient complained of constant back pain, worst in the morning. The pain was exacerbated by prolonged sitting/standing and was relieved by position changes and TENS unit.
Pertinent physical examination findings included painful lumbar extension, positive facet loading, sacroiliac joint tenderness, 4-5/5 lower extremity strength, and slightly diminished ankle jerk bilaterally.
The Intracept procedure is indicated for this patient with more than six months of chronic low back pain with MRI-confirmed Type 1 Modic changes from L3-S1 and has not achieved sustained relief from at least six months of conservative treatment. According to evidence-based literature, basivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options.
Therefore, based on the documentation reviewed and peer-reviewed literature, the request for the Intracept procedure likely to be more beneficial for this patient than other treatment.