Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Ablative Treatment for Spinal Pain (Intracept procedure).
The insurer denied the Ablative Treatment for Spinal Pain (Intracept procedure).
The denial is upheld

The patient is a male with a history of chronic low back pain. He has failed MBB (medial branch blocks) Motrin, Tylenol, muscle relaxants, and tramadol. He is in osteopathic manipulation and PT (physical therapy) with no relief. MRI (magnetic resonance imaging) showed Modic change at L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra), facet arthropathy L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and L5-S1 (fifth lumbar spine vertebra-first sacral vertebra). Physical exam was Positive only for facet loading maneuvers.  An Intracept procedure has been recommended.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient is a male with a history of chronic low back pain. He has failed MBB (medial branch blocks) Motrin, Tylenol, muscle relaxants, and tramadol. He is in osteopathic manipulation and PT (physical therapy) with no relief. MRI (magnetic resonance imaging) showed Modic change at L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra), facet arthropathy L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and L5-S1 (fifth lumbar spine vertebra-first sacral vertebra). Physical exam was Positive only for facet loading maneuvers.  An Intracept procedure has been recommended.

The procedure was denied coverage by the health plan as not medically necessary. This was appealed.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, this patient has not failed common treatments for axial low back pain such as sacroiliac (SI) joint interventions, which are common causes of axial low back pain. In situations where all non-invasive options have failed, epidural steroid injections could also be considered, although typically used in patients with radicular symptoms. Spinal cord stimulation is also an alternative, but has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose.

Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. There is only documentation of a "remote history" of epidural steroid injections, which do not show strong results in the treatment of axial low back pain. Given that multiple proven and effective less invasive options have not been failed, the requested Intracept procedure is not medically necessary.