Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Nerve treatment in the spine - Intracept Procedure. 
The insurer denied the nerve treatment in the spine - Intracept Procedure. 
The determination is upheld. 

This is a female patient diagnosed with low back pain. Records provided show that a request for the patient to undergo the Intracept procedure (interosseous ablation of the basivertebral nerve) was denied by the health plan. 
The patient has a history of low back pain that began 10 years ago and partially worsened over the last 10 months. She has had multiple treatments including activity modification, heat, ice, home exercises, lumbar epidural injections, medial branch blocks, medication management, physical therapy, radiofrequency ablation, and trigger point injections. Medications have included Lyrica, meloxicam, tramadol, Tylenol and Xanax. The pain is impacting activities of daily living and nothing has provided sustained relief. It was reported she had magnetic resonance imaging (MRI) performed demonstrating Modic type II changes at disc spaces lumbar (L) 4 - L5 and L5 - sacral (S) 1 and the provider believes that this is the source of the patient's chronic back pain. 
Magnetic resonance imaging (MRI) of the lumbar spine revealed scoliosis; degenerative disc disease most pronounced at L1-L2 with type 1 endplate Modic changes; additional stable multilevel degenerative changes. 
A progress note outlines the patient with a history of chronic low back pain present for more than 10 years. The patient has tried and failed conservative treatment including medication and physical therapy. On physical examination, the patient had limited lumbar range of motion, facet loading bilaterally reduced in low back pain. There was pain with percussion at the lumbosacral junction and tenderness to palpation at the left sacroiliac (SI) joint. Motor strength, sensation, and reflexes were intact. There was a lengthy list of prior procedures the patient has had including multiple lumbar epidural injections, SI joint injections, greater trochanteric injections, hip injections, medial branch blocks, radiofrequency ablation with varying degrees of benefit. It was recommended the patient undergo the Intracept procedure and this is under review for medical necessity. 

The requested health service/treatment of nerve treatment in spine is not medically necessary for this patient. The patient has a history of chronic back pain and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation [BVN]) as the provider states that the patient's MRI shows Modic type II changes at L4 - L5 and L5 - S1. However, it should be noted that the MRI report did not mention Modic type II changes at any level and did note Modic type I changes most pronounced at L1 - L2. There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. There is insufficient 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. Additional studies are needed to evaluate long-term risks and benefits of this procedure.