Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (procedure code 64628, 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(procedure code 64628, 64629)
The denial is upheld.

The patient is an adult male. He has chronic low back 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 physical therapy (PT), epidural steroid injections, facet injections, sacroiliac (SI) joint injections, and home exercises. The patient has failed multiple medications, including muscle relaxants and non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) does not 
show Modic changes. Physical exam does not reveal any neurological injury. 

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. 
The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male. He has chronic low back 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 physical therapy (PT), epidural steroid injections, facet injections, sacroiliac (SI) joint injections, and home exercises. The patient has failed multiple medications, including muscle relaxants and non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) does not show Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new United States 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 has been shown effective in randomized controlled trials with five-year results. 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, this patient has not failed radiofrequency ablation (RFA) for his facet-mediated pain. The patient reportedly had positive results to diagnostic medial branch blocks, but then was treated with platelet-rich plasma (PRP) injection as opposed to radiofrequency ablation, which is a common treatment of axial low back pain. Radiofrequency ablation has been shown to be effective in the literature, while platelet-rich plasma has not. In addition, no Modic changes are seen on the magnetic resonance imaging scan. The Intracept procedure should be employed after 
all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate. Therefore, the health plan should not cover the requested health service.