Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain. 
Treatment: 22899 - Intracept procedure. 
The insurer denied the 22899 - Intracept procedure. 
The denial is overturned. 

The patient is a female with diagnosis of lumbar facet arthropathy; vertebrogenic pain; degenerative disc disease, lumbar; and lumbar spondylosis. Treatment history includes ice/heat, medications, physical therapy for several months last year (provided moderate relief of pain), home exercise, lumbar epidural steroid injections times two (x2), lumbar medial branch blocks with excellent relief and lumbar radiofrequency ablation (RFA) which provided good relief of her facet mediated pain. The patient continues to have axial low back pain described as an aching discomfort that is worse with prolonged activity including sitting and going from sit to stand position as well as prolonged activities. She denies any radicular symptoms or changes in bladder/bowel dysfunction.  

The patient remains pending the Intracept procedure to help with vertebra genicular pain that continues to impede functioning, ability to perform certain activities and has hindered quality of living. Her objective findings demonstrated decreased range of motion with pain on extension/facet loading of her back. Her magnetic resonance image (MRI) of the lumbar spine reported degenerative disc disease at L1-2, bulge with broad-based asymmetric to right herniation and no stenosis; degenerative disc disease at L4-L5 with bulge and central herniation and annular fissure with no stenosis; degenerative disc disease at L5-S1 with bulge and central herniation, nose stenosis; and endplate reactive marrow edema at L5-S1 with Schmorl's node at the inferior L5. The request is for Intracept procedure to L5-S1. 

Yes, the health plan should cover the Intracept procedure. 

Yes, the Intracept procedure is likely to be more beneficial than any standard treatment(s) for the patient's condition. 

According to Morgan Lorio (2020), intraosseous ablation of the basivertebral nerves from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain (CLBP) when all the following criteria are met: 
1) CLBP of at least six months duration, 
2) Failure to respond to at least six months of nonsurgical management, and 
3) MRI-demonstrated Modic change (MC1 or MC2) in at least one vertebral endplate at one or more levels from L3 to S1. 

According to Becker (2017), ablation of the basivertebral nerves 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 one-year study period. 

This patient is a female with chronic back pain, She has tried and failed conservative treatments - home exercise program, physical therapy, medications, lumbar epidural steroid injections, and radiofrequency ablation. Her pain is disabling, affects her quality of life on a daily basis and has been of a long-term duration. Her back pain is associated with Modic changes noted on MRI. She would like to avoid the invasive surgical procedure.  As such, the request is medically indicated based on peer-reviewed literature.