Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Intracept procedure.
The insurer denied the Int.racept procedure.
The denial is overturned

According to the medical record, the patient is a male with history of low back pain. His diagnoses include Lumbar radiculitis, Lumbar spondylosis, Lumbar spinal stenosis, Lumbar degenerative disc disease, Vertebrogenic pain. He has had multiple steroid injections, medial branch blocks and radiofrequency ablations. He reports the pain affects his activities of daily living. He has tried ibuprofen and Zanaflex without substantial relief. He has failed conservative treatment. His MRI (magnetic resonance imaging) shows Modic type 1 changes at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and Modic type 2 changes at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra). The request is for Intracept procedure (intraosseous radiofrequency ablation of basivertebral nerve).

Yes, the health plan should cover the Intracep procedure.
Per the clinical record provided and using peer-reviewed medical literature as explained below, the Health plan should cover the Intracept procedure.

Yes, the Intracept procedure is more beneficial than any standard treatment for the insured's condition or disease.
According to Khalil, current literature suggests that degenerated or damaged vertebral endplates are a significant cause of chronic low back pain (LBP) that is not adequately addressed by standard care. Prior data from the treatment arm of a sham-controlled randomized controlled trial (RCT) showed maintenance of clinical improvements at 2 years following radiofrequency (RF) ablation of the basivertebral nerve (BVN).

According to Fischgrund (2018), patients treated with RF (radiofrequency) ablation of the BVN (basivertebral nerve) for CLBP (chronic low back pain) exhibited significantly greater improvement in ODI (Oswestry Disability Index) at 3 months and a higher responder rate than sham treated controls. BVN (basivertebral nerve) ablation represents a potential minimally invasive treatment for the relief of chronic low back pain.

Per Becker, 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 1-year study period.

Per Smuck, BVN (basivertebral nerve) ablation demonstrates significant improvements in pain and function over SC (standard care), with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.

The patient has diagnoses of Lumbar radiculitis, Lumbar spondylosis, Lumbar spinal stenosis, Lumbar degenerative disc disease, Vertebrogenic pain. He has had multiple steroid injections, medial branch blocks and radiofrequency ablations. He reports the pain affects his activities of daily living. He has tried ibuprofen and Zanaflex without substantial relief. He has failed conservative treatment for more than 6 months. His back pain has been present for more than 6 months. His MRI (magnetic resonance imaging) shows Modic type 1 changes at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and Modic type 2 changes at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra). The request is for Intracept procedure (intraosseous radiofrequency ablation of basi vertebral nerve).

Given the information, the requested Intracept procedure is more beneficial than any standard treatment for the insured's condition or disease.