Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbosacral Degenerative Disc Disease
Treatment Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient was diagnosed with lumbosacral degenerative disc disease. The patient was noted to have complaints of chronic low back pain and presented for consultation for lumbar discography. It was noted that he had progressive worsening over time and the pain was located in the central low back with tightness in the bilateral hamstrings. The patient performed exercises learned from prior physical therapy but they provided no significant relief. Medications included Advil, Percocet and tramadol. The physical examination revealed limited lumbar range of motion with stiffness in the central low back, Kemps test bilaterally produced low back pain, Patrick's test on the left produced mild low back tightness. Lower extremity motor strength, sensation, and reflexes were normal. There was low back pain with femoral stretch test and hamstring discomfort with straight leg raise bilaterally at 85. The prior treatment history included physical therapy without relief, about seven lumbar procedures over the years including epidural steroid injections and radiofrequency ablation without significant sustained relief, and medications. Magnetic resonance imaging (MRI) of the lumbar spine findings included degenerative disc disease with type II Modic and plate changes at lumbar (L) 5-sacral (S) 1 and to a mild degree at L4-L5; foraminal narrowing on the left greater than right at L5- S1 and on the right at L4 - L5; multilevel set arthrosis greatest bilaterally at L3-L4 and on the left at L5-S1. It was recommended that the patient undergo L5 and S1 intraosseous basivertebral nerve radiofrequency ablation (Intracept). At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is a lack of high-quality long-term studies showing this treatment to be as effective or more effective than that of standard means of treatment for this condition and further long-term studies are needed to establish the overall safety and efficacy of this treatment. There is no evidence to suggest that this treatment would be as beneficial or more beneficial than other standard treatments for this patient's condition. The patient has chronic back pain that reportedly is worsening over time. Examination findings suggest the facet joints to likely be a primary pain generator and there are also some findings suggesting a radicular component as well as possible myofascial pain. It is noted the patient has had conservative treatment with varying degrees of benefit including physical therapy, home exercise program, injections, and some medications. Available treatments include chiropractic treatment, acupuncture, and repeat injections given there appears to have been some benefit from prior injection therapy, particularly with facet injections/radiofrequency ablation; medications such as muscle relaxants, nonsteroidal anti-inflammatory drugs, antidepressants and/or anticonvulsants. An MRI shows facet arthrosis is likely a pain generator as well as foraminal narrowing. Surgery may be a consideration if other forms of conservative management failed to produce significant improvement in symptoms.

The health plan's determination is upheld.