Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative Disc Disease

Treatment: 22899, unlisted procedure, spine (INTRACEPT Procedure) and C9752 (destruction of intraosseous basivertebral nerve, verts two vertebral bodies, including imaging guidance, lumbar/sacrum).

The insurer denied the 22899, unlisted procedure, spine (INTRACEPT Procedure) and C9752 (destruction of intraosseous basivertebral nerve, verts two vertebral bodies, including imaging guidance, lumbar/sacrum). 

The denial was upheld.

This is a male patient with a past medical history of low back pain, bilateral primary osteoarthritis of the knee, vertebral genic pain, facet arthropathy, lumbar and long-term prescription opiate use.  The patient's magnetic resonance imaging (MRI) of the lumbar spine revealed increased degenerative changes at L3-4 with impingement of the descending bilateral L5 nerve roots and mild central canal stenosis and moderate foraminal narrowing.  There was an otherwise stable examination with foraminal narrowing at L4-5 compressing the exiting left L5 nerve roots with mild central canal stenosis and impingement of the descending right L5 nerve roots.  There was foraminal narrowing at L5-S1 compressing the exiting bilateral L5 nerve roots.  The progress note indicated that the patient was to undergo physical therapy for the bilateral knees.  The patient was to undergo an Intracept procedure under fluoroscopic guidance for low back pain with associated Modic changes that were noted on his MRI.  The patient had undergone bilateral lumbar epidural steroid injections and radiofrequency ablations.  The provider letter was requesting prior authorization for the intraosseous ablation procedure of the basivertebral nerve which was accomplished through the Intracept procedure.  The patient was recently diagnosed with intestinal bleeding, which prevented him from using nonsteroidal anti-inflammatory drugs.  The patient's pain had been getting progressively worse over the last several months.  The patient was complaining of constant pain that was exacerbated with increased physical activity and was worse at the end of the day.  A Magnetic Resonance Imaging (MRI) was performed that revealed Modic type II changes at L2-L3 and L4-L5 disc spaces.  It was noted as such the chronic low back pain was coming from the vertebral genic changes at L3, L4, and L5 vertebral bodies.  The provider noted that the best solution was the Intracept procedure as nothing was going to abate this patient's back pain generated by the basilar vertebral nerves short of its ablation.  The request was received for the Intracept procedure.

The role of radiofrequency ablation for low back pain is summarized by Up to Date as follows; 
"We suggest not using radiofrequency denervation for the management of chronic low back pain.  The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit [57-66].  When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit."

There is insufficient clinical evidence in the literature to support the use of Intracept for this patient's treatment.  There is insufficient data to support that this procedure is more beneficial than other standard treatments such as physical therapy, therapeutic home exercise program, anti-inflammatory medications and spinal injection. 

The carrier's denial of 22899, unlisted procedure, spine (INTRACEPT Procedure) and C9752 (destruction of intraosseous basivertebral nerve, verts two vertebral bodies, including imaging guidance, lumbar/sacrum) should be upheld.