Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: Intracept Procedure 
The insurer denied the Intracept Procedure.
The denial is overturned. 

According to the medical records, the patient is a male with diagnosis of Lumbar spondylosis and Vertebrogenic pain. He has tried multiple treatments that included facet blocks, facet RF (radiofrequency) ablation, physical therapy, chiropractic care, ice, heat, NSAIDs (nonsteroidal antiinflammatory drugs), analgesics, rest and activity modification. The pain has significant impact upon ADLs (activities of daily living). Nothing has provided sustainable relief. 

The patient's MRI demonstrated Modic type degenerative endplate changes at L4-5 disc spaces. As such his chronic low back pain is coming from the vertebrogenic changes at L4 and L5 vertebral bodies. His presentation does not warrant any type of fusion or disc replacement surgery. 

Yes, the health plan should cover the Intracept Procedure (22899, C9752).

Yes, the Intracept Procedure (22899, C9752) is likely to be more beneficial.

The INTRACEPT System is the first specific therapy to relieve chronic low back pain (CLBP) of at least six months duration that has not responded to at least six months of conservative care caused by changes associated with degeneration of spinal vertebral bodies and the associated intervertebral discs.

According to Becker (2017), ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the one-year study period.

According to Khalil (2019), minimally invasive radiofrequency (RF) ablation of the basivertebral nerve (BVN) led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related Low Back Pain.

According to Fischgrund (2018), patients treated with radiofrequency (RF) ablation of the basivertebral nerve (BVN) for (chronic low back pain) CLBP exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain.

The patient has diagnosis of Lumbar spondylosis and Vertebrogenic pain.  He has chronic low back pain that has persisted for more than six months (His back pain started while doing some yard work at home). He has exhausted all traditional non-operative measures to resolve his pain including exercise programs and medications. The continued use of Nonsteroidal anti-inflammatory drugs is not in the best interest due gastrointestinal and renal side-effects. The continued use of long-term narcotics is not advisable due to concerns of substance abuse disorder. His MRI shows Modic changes at L4-L5 that is consistent with causing vertebrogenic pain. His presentation does not warrant any type of fusion or disc replacement surgery. 

Given the clinical information, the debilitating nature of the patient's axial back pain and the radiological findings of Modic Type changes consistent with vertebrogenic pain, the request is medically appropriate.