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 female patient who is diagnosed with low back pain. According to the records provided, the patient was recommended to undergo intraosseous basivertebral nerve ablation, which the health plan denied. 
A letter of appeal from the provider states that the provider does not agree that the procedure is experimental and investigational and states that this is an innovative procedure to address chronic low back pain, fulfilling a treatment gap for patients with chronic back pain. The provider notes that the patient's primary problem is chronic low back pain due to degenerative disc disease that resulted in the development of vertebrogenic pain identified by Modic changes on magnetic resonance imaging (MRI). The provider states that the patient's low back pain began over one year ago. She has tried multiple treatments including chiropractic care, medication management and physical therapy. Medication has included Advil. The pain is impacting activities of daily living and nothing has provided sustained benefit. The pain is rated at 10/10. The provider states the patient had magnetic resonance imaging (MRI) performed demonstrating Modic changes at disc spaces lumbar (L)3 - L4, L4 - L5 and L5 - sacral (S) 1. The provider feels that the patient's chronic back pain is coming from these vertebrogenic changes.
Per a progress note, the patient was seen regarding chronic back pain rated at 10/10 with radiation into the left buttock and groin. It was noted that the symptoms started many years ago but exacerbated  after a boat ride and has gradually worsened. The patient has had motor vehicle accidents over the years. It was noted that she currently takes Advil with minimal relief. She has associated muscle spasm. She has not previously had physical therapy. Pain is rated at 10/10 in the back and 10/10 leg. The physical examination was unremarkable. It was noted range of motion was within normal limits, motor strength 5/5, reflexes were normal, sensation was normal, and special tests were all negative. It was recommended that 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 to suggest 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. The patient has a history of chronic back pain with symptoms and lower extremities. However, the physical examination was noted to be normal. The provider feels that the patient's pain is coming from Modic changes. However, the MRI shows multiple abnormal findings at multiple levels likely responsible for the patient's pain including disc herniation and multilevel facet arthropathy. The only medication the patient was noted to have tried was over-the-counter (OTC) Advil and although the letter of appeal states that the patient has tried and failed physical therapy, it was noted on the actual progress note that the patient has not previously had physical therapy."
There are a lack of high quality studies evaluating the long-term risks and benefits of the requested procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.