Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Pain. 

Treatment: 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum. 

The insurer denied coverage for 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum. 

The denial is upheld. 

This case involves a patient who has a history of low back pain.  The documentation indicated she has previously undergone bilateral confirmatory L[lumbar]3, L4 and L5 medial branch blocks as well as facet steroid injections.  She reported 100% [percent] relief for several days.  The submitted documentation indicated she continued to deny leg pain.  According to the patient it has severely impeded on her quality of living and overall function.  The submitted documentation indicated she has undergone multiple injections as well as a decompression at the L4-L5 level.  Upon physical exam there was decreased range of motion and pain with extension and facet loading.  The physician referenced prior magnetic resonance imaging (MRI) findings and indicated the patient had vertebral genic pain.  It was recommended she continue to perform home exercises as she deferred physical therapy services due to cost.  It was also recommended she undergo the requested procedure due to Modic changes at the L3, L4, and L5 levels.  It was also recommended they check her MRI prior to proceeding giving anomalous lumbar spine.  An MRI revealed Modic type I degenerative changes involving the endplates at the L4-L5 level. 

There is peer reviewed literature supporting the intracept procedure as requested. 
The intracept procedure does have official regulatory approval where required from the appropriate regulatory bodies.  This patient does appear to be a good candidate for this procedure based on imaging and data reviewed.  As the patient has trialed and failed other treatment options this is the next best option for her.  However, based on the clinical notes she was to be scheduled for a lumbar radiofrequency ablation (RFA), these results are not provided.  Although there are specific risks to each procedure, in general interventional spinal procedures have many of the same shared risks. 

As the patient has failed more conservative treatments to date, this would be an appropriate next step once her documented failure to the planned lumbar RFA is noted. This procedure is not likely to be more beneficial than any other standard services. 

The carrier's denial of 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/ sacrum; C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including guidance (e.g., fluoroscopy), lumbar/ sacrum should be upheld.