Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: 22899 (Intracept) Unlisted procedure, spine
C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum
C9753 - Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)
64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

The insurer denied the 22899 (Intracept) Unlisted procedure, spine
C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum
C9753 - Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)
64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is upheld

The patient is a male. He has chronic low back pain that has not responded NSAIDs (nonsteroidal anti-inflammatory drugs), PT (physical therapy), HEP (home exercise program), ESI (epidural steroid injection). There is description of a plan for MBBs (medial branch block) and subsequent RFA (radiofrequency ablation), however no documentation of this is included. MRI (magnetic resonance imaging) shows mild degenerative changes with Schmorl's nodes, and no true documentation of Modic changes. Exam shows facet loading, and extension based pain. An Intracept procedure has been recommended.

The procedure was denied coverage by the health plan as experimental/investigational. This was appealed.

No, the health plan should not cover the Intracept procedure.
The patient is a male with chronic low back pain that has not responded NSAIDs (nonsteroidal anti-inflammatory drugs), PT (physical therapy), HEP (home exercise program), ESI (epidural steroid injection). There is a description of a plan for MBBs (medial branch blocks) and subsequent RFA (radiofrequency ablation).  MRI (magnetic resonance imaging) shows mild degenerative changes with Schmorl's nodes and no true documentation of Modic changes. Exam shows facet loading, and extension based pain.

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 I or type II 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.

However, the patient has not failed sacroiliac (SI) joint interventions, which is common cause of axial low back pain. In fact, there is no documentation that the patient has failed facet interventions, which is also a common cause of low back pain. In the attached documentation there is a plan to proceed with MBBs (medial branch blocks), but no additional information is available on the results.  In addition, the MRI (magnetic resonance imaging) reports only mild degenerative with Schmorl's nodes, and no specific documentation of significant Modic type 1 or 2 changes. There is mention of "mild scattered degenerative changes." Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. Given the above, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.