Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (BVN) Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation (BVN) Procedure.
The determination is upheld.

This is a male patient with complaints of neck and low back pain. He has low back pain in his left lower back. Prior treatments include chiropractic care and epidural steroid injections many years ago with some relief. He is currently doing a home exercise program as tolerated. The physical examination notes a musculoskeletal examination showing tenderness to lumbar paraspinal musculature, and positive trigger point. Magnetic resonance imaging (MRI) of the lumber spine notes multi-level degenerative changes throughout the lumbar spine. The treating provider suggested the Intracept procedure. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. There should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between lumbar (L) 3 and sacral (S) 1 on magnetic resonance imaging.
According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)."
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial.
As cited above, Becker. et.al trial indicated only a 17-patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. In addition, no United States (U.S.) guidelines based on research recommend this treatment. Therefore, intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) is considered investigational as a treatment for low back pain. The proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.