Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance
The insurer denied the Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance.
The denial is upheld. 

Patient is a male with a history of lower back pain for greater than two decades duration.  He states that the pain started from playing basketball.  He has had conservative treatments, including facet injections, prescription and over-the-counter pain medication, and physical therapy.  The pain is severe (7/10) and has had significant impact on activities of daily living and his ability to perform his job.

The patient's examination shows motor and sensory exam is intact with no pathologic reflexes.

The patient's MRI (magnetic resonance imaging) showed mixed Modic type I and II changes at L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra).

The patient's provider has diagnosed a vertebrogenic source of pain.  The provider recommends basivertebral nerve ablation.

The health plan has denied the procedure as being experimental/investigational.  The treating provider is appealing this because there is evidenced-based literature supporting the procedure.

No, the health plan should not cover the requested health service.

The Intracept procedure is not medically appropriate for this patient, as this procedure is considered experimental/investigational, as there is insufficient evidence to support its routine use at the current time.  This is based on current available literature.

Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve as treatment of low back pain is limited to one randomized control trial and other low-level studies.  The studies have not demonstrated long-term improvements in pain patient health outcomes, including pain and disability measures.  Further reproducible large clinical studies are needed to study intraosseous basivertebral nerve ablation before clinicians can confidently apply this treatment in their practice.  In addition, no US (United States) guidelines based on research recommend this treatment.  Therefore, this treatment is considered investigational at this time.

The procedure has not yet become a standard of practice based on current evidence-based recommendations.  This has not yet been definitively shown to be beneficial.

No, there is not sufficient literature to support that the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

There are no specifics of this case that warrant overturning of the health plan's denial of this device and procedure.  There is a growing body of literature evaluating intraosseous basivertebral nerve ablation, and it may bear this out to be a medically appropriate procedure in the future.  However, it is currently still considered experimental/investigational.  Furthermore, the North American Spine Society does not address this procedure in its clinical practice guidelines.