Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Nerve treatment of the spine.
The insurer denied nerve treatment of the spine.
The denial is upheld. 

This is a patient diagnosed with low back pain. There is a letter of appeal stating that the patient has a history of low back pain that began several years ago and has had multiple treatments including activity modification, caudal epidural steroid injection, home exercises, medication management and physical therapy. It was noted that medications have included ibuprofen, Lyrica, and Percocet. Pain is impacting activities of daily living, and nothing has provided significant relief. Pain is rated at 8/10. The provider states the patient had a magnetic resonance imaging (MRI)  showing Modic changes at lumbar (L)4 - L5 disc space and therefore the patient's pain is coming from vertebrogenic changes at L4 and L5. 
Progress report notes the patient was noted to have complaints of chronic back pain. It was noted he would like an epidural steroid injection for relief and would also like the Intracept procedure. He had low back pain greater than lower extremity pain. Pain was described as burning, throbbing, cramping, numbness, pins, and needles. There was no physical exam performed secondary to telehealth visit. 
An MRI of lumbar spine revealed multilevel degenerative disc disease without significant spinal canal stenosis or neural foraminal narrowing. At L5 - sacral (S)1, calcification in the disk space is present and correlates with the previous computed tomography (CT) scan of the pelvis.
At issue is the medical necessity of nerve treatment in spine.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Nerve treatment in spine is not medically necessary for this patient.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). 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. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required." The International Society for the Advancement of Spine Surgery's guideline on "Intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain" (Lorio et al, 2020) stated that intraosseous ablation of the basivertebral nerve (BVN) is a new procedure; its limitations included industry funding is a potential source of study bias for the available data reviewed, limited number of studies, short-term follow-up for the majority of studied patients, and unknown effect on the primary degenerative process."
This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence and 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. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Therefore, the requested health service/treatment of nerve treatment in spine is not medically necessary.