Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Degenerative Disc Disease
Treatment: Intercept Procedure
The health plan has denied the requested procedure. 
The health plan determination is overturned.

The patient has chronic low back pain (CLBP).  The patient underwent a microdiscectomy with a resolution of  pain, however,  back pain was exacerbated without any inciting event, trauma, or injury. The patient was diagnosed with lumbar facet arthropathy, chronic bilateral lower back pain without sciatica, and vertebrogenic pain.

Treatment history includes lumbar epidural steroid injections X 3 with no relief; massage therapy, acupuncture, and physical therapy with minimal pain relief.

The magnetic resonance imaging of the lumbar spine post- intravenous contrast revealed mixed type I/II Modic endplate changes at L4-L5.

The patient received medial branch block/facet injection at L3, L4, and L5 bilaterally. The patient reported 80% relief in recovery, and great pain relief for several weeks, as well as improved function and reduction in Advil usage.

The patient received repeat medial branch block/facet injection and reported 80% pain relief of low back pain for one week duration.

It was indicated that the patient's low back pain had gradually returned. The patient reported that pain was exacerbated with prolonged sitting and standing and was relieved with positional changes and Advil during severe cases. The patient remained limited due to the pain.

The proposed treatment (Intracept procedure), destruction of the intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g.fluoroscopy), lumbar/sacrum appears likely to be more beneficial than any standard treatment or treatments for the patient's disabling condition.

The patient was diagnosed with lumbar facet arthropathy, chronic bilateral lower back pain without sciatica, and vertebrogenic pain.

Treatment history includes lumbar epidural steroid injections X 3 with no relief; massage therapy, acupuncture, physical therapy with minimal pain relief, and a microdiscectomy. 

The patient underwent a microdiscectomy  with  resolution of pain, however,  back pain was exacerbated  without any inciting event, trauma, or injury. The MRI of the lumbar spine post-IV contrast revealed mixed type I/II Modic endplate changes at L4-L5.

The patient received medial branch block/facet injection at L3, L4, and L5 bilaterally with 80% relief in recovery, and great pain relief for several weeks, as well as improved function and reduction in Advil usage. The patient received repeat medial branch block/facet injection  and reported 80% pain relief of low back pain for one-week duration.
However, it was indicated that the patient's low back pain had gradually returned. 

Based on peer-reviewed literature, radiofrequency ablation of the basivertebral nerve is a safe and effective minimally invasive treatment for the relief of chronic low back pain in patients with Type 1 or 2 Modic changes. Patients treated with radiofrequency ablation of the basivertebral nerve for basivertebral nerve exhibited sustained clinical benefits in Oswestry Disabilty Index and Visual Analog Scale and maintained high responder rates at 2 years after treatment. This therapy reported statistically significant improvements from baseline at all time points through 2 years of follow up. Basivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of CLBP in a patient population that typically has few effective treatment options.

Considering the patient's refractory back pain post-microdiscectomy and MRI findings of Modic endplate changes, the request for the Intracept procedure is likely to be more beneficial for this patient.