Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The insurer denied: 64628: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first two vertebral bodies lumbar or sacral; and 64629: Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. 
The denial is upheld. 

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy) and epidural steroid injections. The patient has failed medications including NSAIDs (nonsteroidal anti-inflammatory drugs). MRI (Magnetic resonance imaging) shows Modic changes. The patient's physical exam does not reveal any neurological injury. 

The health plan should not cover the requested health service. 

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy) and epidural steroid injections. The patient has failed medications including NSAIDs (nonsteroidal anti-inflammatory drugs). MRI (Magnetic resonance imaging) shows Modic changes. The patient's physical exam does not reveal any neurological injury. 

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trials) with 5-year results. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. 

However, the patient has not failed or attempted sacroiliac joint injections or facet joint interventions, which are common causes of axial low back pain. It is not evident that the patient has undergone the suggested medial branch blocks, or at least no documentation of the results is available. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.