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 with low back and lower extremity (Right > [greater than] Left) pain. He had a bilateral L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) TFESI (Transforaminal Epidural Steroid Injection), which provided complete pain relief for one month. He tried physical therapy, massage, electro-stimulation, aleve, and OTC (over the counter) analgesics without benefit. MRI (magnetic resonance imaging) of the lumbar spine is significant for disc bulging, degenerative disc disease, and nerve root impingement. Examination is significant for right sided straight leg raise.

Request for Intracept procedure was denied coverage by the health plan as experimental/investigational. This is being appealed.

No, the health plan should not cover the requested Intracept procedure for this patient.
A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms.  There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition.  It must be necessary to meet patients basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests that Intracept is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

While degenerative changes are noted on MRI (magnetic resonance imaging), degenerative changes are not necessarily Modic changes. Furthermore, the patient does not meet inclusion and exclusion criteria in the current published studies.  As such, the Health plan should not cover the Intracept procedure for this patient.

No, the requested Intracept procedure is not more beneficial than any standard treatment for the insured's condition or disease.