Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/Intraosseous basivertebral nerve ablation.
The health plan denied the requested Intraosseous basivertebral nerve ablation as experimental/investigational. 
The health plan's determination is upheld.

The provider states that the patient has a history of low back pain that began over three years ago. He has tried multiple treatments including acupuncture, chiropractic, facet injections, home exercises, massage therapy, medication management and physical therapy. Medications have included non-steroidal anti-inflammatory drugs (NSAIDs) and Tizanidine. Pain is impacting activities of daily living and nothing has provided significant relief. Pain ranges from 7-10/10. The provider states that the patient had a magnetic resonance imaging (MRI) showing mixed Modic type I and II changes that disk space is (lumbar) L4 - L5 and the provider believes that this is the source of the patient's pain. The provider requests reconsideration for approval of this procedure.
An MRI of lumbar spine dated revealed progression of L4 - L5 degenerative disc disease. No significant change in previously noted broad-based central and right parasagittal and foraminal disc protrusion; right severe neuroforaminal stenosis, progress compared to prior study. There was noted to be endplate degenerative signal alterations most pronounced at L4 - L5 level, not seen on prior study.
At issue is whether the proposed health service or treatment of an Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, the proposed health service or treatment Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The International Society for the Advancement of Spine Surgery's guideline on "Intraosseous ablation of the basivertebral nerve (BVN) for the relief of chronic low back pain" (Lorio et al, 2020) stated that intraosseous ablation of the BVN is a new procedure; its limitations included industry funding is a potential source of study bias for the available data reviewed, limited number of studies, short-term follow-up for the majority of studied patients, and unknown effect on the primary degenerative process." Per Becker et al, " Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." However, this is noted to be an industry sponsored study and does not demonstrate long term effects of the procedure beyond one year. Per Fischgrund et al, "Patients treated with radiofrequency (RF) ablation of the BVN for chronic low back pain (CLBP) exhibited significantly greater improvement in Owestry Disability Index (ODI) at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain." Again, there appears to positive initial results, however, the study was fairly small (225 patients with chronic back pain) and there continues to be a lack of long term studies evaluating long term risks/benefits when compared to other standard means of treatment and further large, high-quality studies are needed. This treatment is not currently considered standard of care in the general medical community. 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. The requested procedure is experimental and investigational.