Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Treatment: 22899 Unlisted Procedure Spine (intracept),
C9752 Destruction of Intraosseous Basivertebral Nerve First Two Vertebral Bodies Including Imaging Guidance, Lumbar/Sacrum
The insurer denied the 22899 Unlisted Procedure Spine (intracept),
C9752 Destruction of Intraosseous Basivertebral Nerve First Two Vertebral Bodies Including Imaging Guidance, Lumbar/Sacrum
The denial is upheld

The patient is a female with low back as well as right hip and groin pain for approximately several decades. The patient has tried numerous injections including: TFESI (Transforaminal Epidural Steroid Injection), SIJ (sacroiliac joint), hip injections, MBBs (medial branch blocks), and RFAs (radiofrequency ablations). Her history is significant for left sided L4 (fourth lumbar spine vertebra) radiculopathy status post L2-3 (second lumbar spine vertebra-third lumbar spine verbetra) hemi laminoforaminotomy and discectomy. The patient's pain is rated 3/10. MRI (magneti resonance imaging) lumbar spine shows multilevel disc dissection and height loss as well as Modic type I and II changes, facet arthropathy, moderate spinal stenosis.

The provider is recommending the Intracept procedure, which was denied coverage by the health plan as experimental/investigational. This is being appealed.

No, the health plan should not cover the 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 this procedure 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.  At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. Furthermore, this patient does not meet the inclusion and exclusion criteria in the current industry sponsored literature. Specifically, pain is not a minimum of 4/10, patient has radicular pain as well as a history of previous lumbar surgery, and current radiographic imaging shows other causes of low back pain. 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.
Other treatment options for this patient's condition may include non-opioid medications (e.g., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (e.g., physical therapy, home exercise program, chiropractor treatments) interventions (e.g., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions). The Intracept procedure is not considered more beneficial than any standard treatment for the insured's condition or disease (see above, question 1).