Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back and Neck Pain. 
Treatment: 22899 unlisted procedure, spine (Intracept), C9752 and C9753 (Destruction of intraosseous basivertebral nerve). 

The insurer denied coverage for 22899 unlisted procedure, spine (Intracept), C9752 and C9753. 

The denial is upheld. 

This patient has chronic low back pain. A lumbar spine magnetic resonance imaging (MRI) revealed multiple disc bulges associated with moderate to severe spinal canal stenosis and foraminal stenosis at multiple levels. Modic type I endplate changes were seen at lumbar (L) 3-4 and L 4-5. 

The member reported back and neck pain. Leg pain was denied. Prior treatment included two weeks of home physical therapy after a mastectomy. She was not undergoing any formal therapy. Prior treatment included multiples epidural steroid injections, medial branch blocks, and facet radiofrequency ablation. Medial branch blocks yielded 80 to 100 percent (%) relief of pain. On physical examination, there was "subjective" reduction in range of motion of the back. It was reported that the member had failed over six months of conservative treatment, which had included a home exercise program, physical therapy, injections, and medications. It was not addressed whether there was any physical therapy other than post-mastectomy physical therapy for two weeks.

Two separate prospective randomized controlled trials showed improvements in pain and function when Intracept was used to treat low back pain that was refractory to conservative care and that was associated with Modic type 1 or 2 endplate changes on MRI.  The procedure is Food and Drug Administration (FDA) approved.  The records show that two sets of diagnostic lumbar medial branch blocks yielded positive responses of 80% to 100%. Diagnostic medical branch blocks are the gold standard for determining whether or not low back pain is attributable to the lumbar facet joints. This response indicates that lumbar facet joints are the primary pain generator in this case. The Intracept procedure does not treat facetogenic low back pain. 

In addition, the records are unclear as to whether or not (or when) the member underwent a trial of formal physical therapy for the low back. The only documented physical therapy was a two-week postoperative course after mastectomy surgery. Intracept would not be indicated prior to trials of first-line conservative treatment including formal physical therapy. 

As noted above, low back pain is facetogenic and the member may not have had a meaningful trial of formal physical therapy directed to the low back. 

"Conservative management often includes over-the-counter pain medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Muscle relaxers, gabapentin, topical analgesics, and opioids all play a role in the management of back pain, on a case-by-case basis. Most cases of back pain are mechanical in origin and respond to activity modification, rest, ice, and heat. Physical therapy and core strengthening exercises also play a role." (Casiano, V. E. et al.). 

Intracept is an invasive procedure with increased risks, in comparison to conservative treatments like physical therapy.  The pain is facetogenic and would not be expected to respond to the Intracept procedure. 

The carrier's denial of 22899 unlisted procedure, spine (Intracept), C9752 and C9753 should be upheld.