Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The insurer denied the Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The denial is overturned.

The patient is a male with a history of low back pain that goes back more than six years. He attributes his pain to long-term wear and tear working as a landscaper and heavy equipment operator. He has had multiple treatment that included interlaminar lumbar epidural steroid injection, physical therapy, physician directed home exercise program, chiropractic manipulation, epidural steroid injections, radiofrequency ablation, medial branch blocks and medication management. The patient has had a significant impact upon activities of daily living. Medications have included Lidoderm patch, Neurontin, Tylenol and Zanaflex created nothing has provided significant sustainable relief. The severity of the pain is visual analog scale (VAS) of 8/10.

The patient had an MRI (magnetic resonance imaging) performed which shows Modic type 1 and 2 changes at L3-4 (third lumbar spine vertebra - fourth lumbar spine vertebra), L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra), and L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) disc spaces. As such, his chronic low back pain is coming from the vertebral genicular at L3 (third lumbar spine vertebra), L4 (fourth lumbar spine vertebra), L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra). His pain is disabling and affects the quality of life on a daily basis. The chronic low back pain has persisted for more than six months.

The provider believes that intercept procedure is medically appropriate for this patient.

Yes, the health plan should cover the intracept procedure.

Yes, Intracept is likely to be more beneficial.
Per Becker, Lumbar axial back pain arising from degenerative disc disease continues to be a challenging clinical problem whether treated with nonsurgical management, local injection, or motion segment stabilization and fusion. Ablation of the basivertebral nerve (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 one-year study period.

Per Khalil, minimally invasive RF (radiofrequency) ablation of the BVN (basivertebral nerve) led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related low back pain.

The patient has exhausted all traditional non operative measures to resolve his pain.  Repeating treatment that have failed to provide sustainable long-term pain relief is not indicated.  The long term use of NSAIDs (nonsteroidal anti-inflammatory drugs) and opioids are not ideal given the current opioid substance abuse problem in the United States, and the effects they have upon the stomach, liver and kidney.  Modification or changes will unlikely have an impact upon his pain.  His MRI (magnetic resonance imaging) demonstrates degenerative endplate Modic changes that is consistent with and causing vertebra genicular pain.  Nothing is going to abate the pain generated by the base the vertebral nerve short of ablation.  His presentation does not warrant any type of fusion or disc replacement surgery.  However he needs relief from his ongoing axial pain.  The provider believes that intercept procedure is medically appropriate for this patient.

The patient has failed conservative therapy for more than six months-home exercise program, physical therapy, medications and injection.  His back pain is present for more than six months.  His image studies shows Modic changes at L3 (third lumbar spine vertebra), L4 (fourth lumbar spine vertebra), L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra).   As such, the request is appropriate and should be covered by the health plan.