Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient who was diagnosed with low back pain. Records provided show that the patient was recommended to undergo the Intracept procedure.
The provider noted the patient's primary problem is chronic low back pain due to degenerative disc disease that has resulted in developing vertebrogenic low back pain identified by Modic changes on magnetic resonance imaging (MRI). The patient's back pain began more than one year ago and multiple treatments have an attempted including injections, medial branch blocks, medications, radiofrequency ablation, sacroiliac (SI) joint injections, epidural steroid injections. The patient has tried medications including Medrol Dosepak and methocarbamol. Pain is rated at 9/10 and pain is impacting activities of daily living. The provider noted the patient had an MRI that demonstrated Modic type I changes at disk bases lumbar (L) 5 and sacral (S) 1 and the provider believes that this is where the patient's chronic low back pain is coming from. The provider has requested that the denials be overturned.
Per a progress note, the patient was seen regarding chronic lateral low back pain rated at 9/10. He also complains of numbness and tingling of the affected limbs, muscle spasm and difficulty with ambulation. The patient is having difficulty with activities of daily living. Current medications include Medrol Dosepak and methocarbamol. It was noted the patient had lumbar epidural injection, lumbar medial branch blocks and lumbar radiofrequency ablation (response to these procedures not documented). He was also noted to be status post sacroiliac (SI) joint injection bilaterally which provided 80 percent (%) pain relief. The physical exam revealed spasm and tenderness with tight muscle band at the paravertebral muscles. The plan was to continue methocarbamol, physical therapy was ordered, and it was noted they would request approval for the Intracept procedure and the Intracept procedure is under review.
The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient was noted to have complaints of chronic back pain that the provider believes is coming from Modic changes, although there were no Modic changes noted on MRI. There were multiple other findings that would be considered pain generators, however. The most recent note indicated the patient being referred for a trial of physical therapy and also noting the patient had significant 80 percent (%) improvement in pain from recent bilateral SI joint injections. There are a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment.