Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Back Pain.
Treatment: Surgical Services (All).
The health plan denied the requested Intracept procedure. 
The health plan's determination is upheld.

This is a patient who has a history of chronic low back pain.
The provider states that this procedure is founded on 30 years of basic science research linking Mobic changes to chronic low back pain. The provider states this procedure is an innovative procedure to address chronic low back pain and fulfills a treatment gap for patients with low back pain, that the patient has a history of low back pain that began several years ago and has had multiple treatments including heat, ice, medication management and physical therapy. Medication has included Celebrex. This has had a significant impact on activities of daily living, and nothing has provided sustained relief. Her pain was rated at 7/10. It was reported she had a magnetic resonance imaging (MRI)  demonstrating degenerative endplate changes at (lumbar) L4 - L5 disc space and therefore this is where her pain is coming from.
A progress report states the patient had complaints of low back pain that does not radiate, rated at 7/10 and is interfering with activities of daily living. It was stated that prior treatment has included physical therapy. Medications for pain include Celebrex. The lumbar exam revealed limited range of motion with pain, positive lumbar facet loading, and negative straight leg raise. The provider states the patient has had non-steroidal anti-inflammatory drugs (NSAIDs), injections, short-acting opioids and multiple weeks of physical therapy and it was recommended the patient undergo the Intracept procedure.
An MRI of the lumbar spine revealed new grade 1 anterolisthesis of L4/L5 and disk uncovering with annular fissure contributing to severe spinal canal stenosis and moderate bilateral neural foraminal stenosis with impingement of the exiting L4 nerves, left greater than right. At (lumbar-sacral) L5 - S1, there is stable mild retrolisthesis and right eccentric disc bulge with slight decrease in size of the central disc protrusion which contacts the descending (sacral) S1 nerve roots and contributes to moderate right and mild left neural foraminal stenosis. There is impingement of the exiting right (lumbar) L5 nerve root.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

No, there is no evidence that the proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Records indicate the patient has persistent back pain and reportedly failed conservative treatment, so the provider has recommended the patient undergo the Intracept procedure. However, although the MRI does show degenerative changes, there are multiple other significant findings on MRI that suggest other obvious causes for the pain such as a new grade 1 anterolisthesis of L4/L5 and disk uncovering with annular fissure contributing to severe spinal canal stenosis and moderate bilateral neural foraminal stenosis with impingement of the exiting L4 nerves, left greater than right. At L5 - S1 there is stable mild retrolisthesis and right eccentric disc bulge with slight decrease in size of central disc protrusion which contacts the descending S1 nerve roots and contributes to moderate right and mild left neural foraminal stenosis. There is impingement of the exiting right L5 nerve root. Based on this MRI, there is no evidence to suggest that the Modic changes are responsible for the patient's pain. This procedure remains experimental and investigational, as there is 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. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary.