Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Nerve Ablation System (64628)
The insurer denied the Intraosseous Nerve Ablation System (64628)
The denial is upheld.

The patient is a male. He presented with chronic low back pain and neck pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational.

The patient has failed conservative treatment in the form of PT (physical therapy) and oral medications, including potent opiate. MRI [magnetic resonance imaging] shows large HNP [Herniated Nucleus Pulposus] with contact of L5 (fifth lumbar spine vertebra) nerve root at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra), similar findings at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) with encroachment on the S1 (first sacral vertebra) nerve root. Physical exam does not reveal any neurological injury. Pain is Flexion based on exam.

No, the health plan should not cover the Intraosseous Nerve Ablation System (64628).

No, the Intraosseous Nerve Ablation System (64628) is not more beneficial.
The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is a male who presents with chronic low back pain and neck pain in whom an Intracept procedure has been requested. The procedure was denied as experimental/investigational.

The patient has failed conservative treatment in the form of PT (physical therapy) and oral medications including potent opiate. MRI (magnetic resonance imaging) shows large HNP (Herniated Nucleus Pulposus) with contact of L5 (fifth lumbar spine vertebra) nerve root at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra), similar findings at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) with encroachment on the S1 (first sacral vertebra) nerve root. Physical exam does not reveal any neurological injury. Pain is Flexion based on exam.

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trials) with 5 year results. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) 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 used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.

However, the patient has not failed or attempted sacroiliac joint injections, has not failed RFA (radiofrequency ablation), and MRI (magnetic resonance imaging) shows no evidence of Modic changes. There is notation of Modic changes in the provider's note, but this is not correlated in the MRI (magnetic resonance imaging) report.  In fact there is a large HNP (Herniated Nucleus Pulposus) at L4-5 (fourth lumbar spine vertebra), which is evidenced to correlate with his PE (physical examination) findings. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed and the pain is evidenced to be related to endplate/Modic changes. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial.

Given the above, the requested Intracept procedure is not medically appropriate for this patient.