Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spondylosis, lumbar spondylosis, vertebrogenic low back pain, and chronic right hip pain. 
Treatment: Nerve treatment in the spine. 

The insurer denied coverage for nerve treatment in the spine. 

The denial is upheld. 

The patient is a female with a history of cervical spondylosis, lumbar spondylosis, vertebrogenic low back pain, and chronic right hip pain. 

The patient's pain management provider appealed the denial of the procedure and noted basivertebral nerve ablation and Intracept procedure is noted to be effective in patients who suffer from chronic back pain. He contended that "if the science is reviewed objectively, there is no basis by which the insurer can support the claim that the Intracept procedure is not a covered benefit." He noted that the procedure is founded on 30 years of basic science research linking Modic changes to chronic low back pain. He noted that the procedure received initial Food and Drug Administration (FDA) clearance in 2016. 

The patient's Nurse Practitioner (NP) noted the patient has 90% relief after left cervical facet injections, and has 80% relief after right cervical facet injections, and also has continued neck and back pain. On exam, the patient's body mass index (BMI) is 33, she had appropriate mood and was in no distress. She had positive right Patrick's sign for low back and hip pain, and she had full strength. Normal sensory exam was noted. Magnetic resonance imaging (MRI) confirmed disk degeneration and Modic changes in the lumbar spine. Intracept procedure at lumbar (L) L4, L5, and sacral (S) S1, and also bilateral medial branch blocks and facet injections from L2-L5 were recommended. 

MRI lumbar confirmed retrolisthesis at L2-3 and L3-4-5, with levoscoliosis and disk desiccation at L1, L2, L3, and L4, enhancing lesion in the right facet of L4 was noted, and edema was noted in the pedicles at L5, and moderate central stenosis was noted at L3 and L4 and L5-S1. 

The pain management provider noted the patient had caudal epidural injection that provided 70% relief and that she now has pain with prolonged activity and overall, her function has improved. She also has numbness in the neck and left side of face, and she is taking Advil as needed. She is engaged in physical therapy (PT) for the left arm. On exam she has positive right Patrick's sign and Fortin finger is positive on the right. Right sacroiliac (SI) joint injection was considered. 

The request is for Intracept procedure at L4-5 and L5-S1; however, the MRI shows fairly well-preserved disk spaces at these levels, and the MRI report shows Modic changes at L2-3 and L3-4 and not at L4-5 or L5-S1. Furthermore, there is edema in the L5 pedicles, and moderate canal stenosis at L3-4, L4-5, and L5-S1 and there is retrolisthesis at L2-3 and L3-4 with levoscoliosis. The provider noted the patient has positive right Patrick's test and Fortin finger test is positive on the right. Therefore, he recommended right SI joint injection. Furthermore, the provider noted that caudal injection had provided relief and the patient was improving with PT and medical therapy. 

In conclusion, the records do not establish that the requested treatment is necessary to treat the moderate canal stenosis, nor to correct the levoscoliosis and the retrolisthesis. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for nerve treatment in the spine is upheld. Medical Necessity is not substantiated.