Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a male patient diagnosed with low back pain. The provider recommended that the patient undergo the Intracept procedure, but this was denied by the health plan. The provider is appealing this determination. Multiple letters of appeal were included in the notes. The provider states that this procedure fills a treatment gap for patients who do not receive adequate relief from traditional conservative methods and don't have instability to indicate that fusion is the appropriate treatment. The provider states the patient has tried and failed conservative treatment without relief and the provider strongly disagrees with the decision to deny the procedure. The provider further outlines that the patient has a history of chronic low back pain. To address his pain, he has had chiropractic care, heat/ice, home exercises, lumbar discectomy and lumbar epidural steroid injections. Prior medication has included non-steroidal anti-inflammatory drugs (NSAIDs). The pain is impacting activities of daily living such as sitting, standing and walking. Nothing has provided significant relief. The pain averages 5/10. The provider states the patient had a magnetic resonance imaging (MRI) scan and the provider's review of the magnetic resonance imaging (MRI) indicated Modic changes at lumbar (L) 4, L5 and sacral (S) 1 vertebral bodies and the provider therefore believes this is the primary source of the patient's chronic back pain.
Per a progress note, the patient was seen regarding chronic low back and mid back pain reporting feeling the same since the last visit with the pain rated at 5/10. Medication includes atorvastatin and lisinopril. The physical examination was normal. It was recommended the patient undergo the Intracept procedure. At issue is whether the 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.
There is no evidence that the proposed health service or treatment Intraosseous Basivertebral Nerve Ablation (BVN) Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a history of chronic back pain and failed conservative treatment as well as injections and discectomy. The provider believes the patient's pain is coming from Modic changes shown on MRI (magnetic resonance imaging), which is possible. However, the patient also has multiple other findings including disc protrusions with approximation of the exiting left L (lumbar) 3 nerve root as well as annular fissures at L4 - L5 and L5 - S (sacral) 1 that are likely pain generators. There are a lack of high quality studies evaluating the long-term risks and benefits of this procedure. 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.