Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is Overturned.

The patient is an adult male with history of chronic low back pain of some months. The pain has affected his ADLs (activities of daily living) and functionality. The treating physician 
concluded that the pain is vertebrogenic and that the patient will benefit from Intracept intraosseous nerve ablation for the ablation of basivertebral nerves at L5 and S1 (lumbar five and sacral one). The patient's MRI (magnetic resonance imaging) lumbar spine showed Modic types 1 signal changes at L5/S1( lumbar five/sacral one). The patient has failed conservative measures including physical therapy, home exercise, spinal injections, NSAIDs (non-steroidal anti-inflammatory drugs), etc.
The health plan denied coverage of the request, citing lack of enough proof or not enough proof that it improves health. They deemed it as investigational. The denial is being appealed.

The health plan should cover the requested health service.

The requested is medically appropriate based on general standard of care for vertebrogenic pain. It also meets the following recommended requirements by Relievant, the Intracept Medical device manufacturer, as per the FDA (United States Food and Drug Administration)-approved requirements and indication for which the device is approved (3):
* Intracept is medically indicated in patients who have:
* A history of low back pain of at least 6 months duration; and
* Failed to respond to at least 6 months of non-surgical management; and 
* MRI (magnetic resonance imaging) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L3 to S1; and
* Activities of daily living that are limited by persistent low back pain; and all other reasonable sources of pain have been ruled out.
Per Khalil J, Smuck M, Koreckij T, et al, "The purpose of this RCT [randomized controlled trial] was to compare the effectiveness of intraosseous RF [radiofrequency] ablation of the BVN [basivertebral nerve] to standard care for the treatment of chronic LBP [lower back pain] in a specific subgroup of patients suspected to have vertebrogenic related symptomatology." Their 
conclusion notes, "Minimally invasive RF [radiofrequency] ablation of the BVN [basivertebral nerve] led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP."
Per a study performed by Fischgrund JS, Rhyne A, Franke J, et al, "The purpose of the present study is to report the 2-year clinical outcomes for chronic low back pain (CLBP) patients treated with radiofrequency (RF) ablation of the basivertebral nerve (BVN) in a randomized controlled trial that previously reported 1-year follow up." The conclusions of this study are cited as, "Patients treated with RF [radiofrequency] ablation of the BVN [basivertebral nerve] for CLBP [chronic low back pain] exhibited sustained clinical benefits in ODI [Oswestry Disability Index] and VAS [Visual Analogue Scale] and maintained high responder rates at 2 years following treatment. Basivertebral 
nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP [chronic low back pain]."
The patient presents with a history of chronic low back pain of more than 12 months. He has tried and failed conservative measures including physical therapy, home exercise, spinal injections, NSAIDs (nonsteroidal anti-inflammatory drugs), etc, all treatment exceeding 12 months. The pain has affected his functionality. The magnetic resonance imaging (MRI) of the lumbar spine showed Modic type 1 changes at lumbar five/sacral one (L5/S1) vertebral body. Therefore, based on the submitted information, current peer-reviewed literature and the current 
standards of care, the requested Intracept Procedure would be considered medically appropriate and not investigational.