Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain. 
Treatment: Spine procedure (INTRACEPT) (C9752 & 22899). 

The insurer denied the Spine procedure (INTRACEPT) (C9752 & 22899).  The denial is overturned. 

The patient is a female. According to the medical records, the patient has a history of low back pain and has progressively worsened. She has had multiple treatments that included medial branch blocks, medication management, radiofrequency ablations, home exercise program and physical therapy. The pain has significant impact upon activities of daily living.  Her MRI (magnetic resonance imaging) demonstrated Modic type degenerative endplate changes at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) disc spaces. As such her chronic low back pain is coming from the vertebrogenic changes at L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra). 

The prior review was denied because Destruction of intraosseous basivertebral nerves was considered experimental/investigational. 

Yes, the health plan should cover the Intracept procedure. 

According to Khalil, current literature suggests that degenerated or damaged vertebral endplates are a significant cause of chronic low back pain (LBP) that is not adequately addressed by standard care. Prior 2-year data from the treatment arm of a sham-controlled randomized controlled trial (RCT) showed maintenance of clinical improvements at 2 years following radiofrequency (RF) ablation of the basivertebral nerve (BVN). 

According to Fischgrund, patients treated with RF (radiofrequency) ablation of the BVN (basivertebral nerve) for CLBP (chronic lower back pain) exhibited significantly greater improvement in ODI (Oswestry Disability Index) at 3 months and a higher responder rate than sham treated controls. BVN (basivertebral nerve) ablation represents a potential minimally invasive treatment for the relief of chronic low back pain. 

Per Becker, ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period. 

Per Khalil, BVN (basivertebral nerve) ablation demonstrates significant improvements in pain and function over SC (standard care), with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

The patient in this case has diagnosis of Spondylosis without myelopathy or radiculopathy, lumbar region. The patient has a history of low back pain that began more than 18 months prior and has progressively worsened. She has had multiple treatments that included medial branch blocks, medication management, radiofrequency ablations, home exercise program and physical therapy. The pain has significant impact upon activities of daily living.  Her MRI (magnetic resonance imaging) demonstrated Modic type degenerative endplate changes at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) disc spaces. As such, her chronic low back pain is coming from the vertebrogenic changes at L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra). 

The prior review was denied because Destruction of intraosseous basivertebral nerves was considered experimental/investigational. 
Based on the information provided and per peer-reviewed literature, the health plan should cover the proposed treatment. 

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.