Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back and Neck Pain. 
Treatment: 22899 unlisted procedure, spine (Intracept), C9752 and C9753 (Destruction of intraosseous basivertebral nerve). 

The insurer denied coverage for 22899 unlisted procedure, spine (Intracept), C9752 and C9753. 

The denial is overturned. 

This is a patient had a lumbar magnetic resonance imaging (MRI) showing lumbar (L)4-5 moderate to severe central and bilateral neural foraminal stenosis (NFS) and L5-S (sacral)1 severe right NFS. Modic type I endplate changes are noted at L3-4 and L4-5. She has chronic back pain and has been treated with radiofrequency ablation (RFA) in the past with 60% (percent) benefit. The pain radiates down posterior bilateral mid-thighs without any lower extremity (LE) weakness or paresthesias. She has been treated with multiple injections. She has failed conservative measures including greater than six months of home exercise program (HEP) and physical therapy (PT). 

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome with Intracept. There are two year results form prospective randomized, double blind placebo, controlled multicenter studies demonstrating benefit  with Intracept.  22899 unlisted procedure, spine (Intracept), C9752 and C9753, does have approval from the Food and Drug Administration (FDA) for this diagnosis. 

This patient is a good candidate for 22899 unlisted procedure, spine (Intracept), C9752 and C9753 as the patient has had a failure of conservative measures for more than six months, with chronic pain to the low back and modic changes on MRI.     The patient has failed conservative measures such as injections, medications, and PT, including HEP. She continues to have pain with radiation to lower extremities.    The adverse risks are not increased over standard treatment/services.   The request services of 22899 unlisted procedure, spine (Intracept), C9752 and C9753 is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The patient has already tried the standard treatments/therapies prior to this, and those treatments have failed. Therefore, this is the best option for this patient at this time given her chronic pain to the low back and modic changes on MRI. 

Fischgrund et al, demonstrated that basivertebral nerve ablation was safe and effective. "There has been extensive direct evidence supporting the vertebral body as a source of LBP (ie, vertebrogenic pain) reported ... the basivertebral nerve (BVN) within each vertebral body has been shown to be a source of transmission of vertebrogenic pain signals in chronic low back pain (CLBP) individuals. Furthermore, correlation between vertebral body pathology and CLBP has also been reported. The Smart trial was designed to test the hypothesis that the BVN plays an important role in the transmission of pain signals in patients with CLBP and exhibiting Modic Type 1 and 2 endplate changes. Initial results of the Smart trial showed that thermal ablation of the BVN is a safe and effective treatment for CLBP patients with this indication.41"
                                                 
The carrier's denial of 22899 unlisted procedure, spine (Intracept), C9752 and C9753 should be overturned.