Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic low back pain

Treatment: pain management; outpatient procedure (Intraosseous Nerve Ablation-Intracept procedure)

The insurer denied coverage for pain management; outpatient procedure (Intraosseous Nerve Ablation-Intracept procedure)

The denial is overturned

This case involves a female with a history of arthritis, lumbar radiculopathy, and meningioma who was being recommended for outpatient interosseous nerve ablation-Intracept procedure. Records indicated the patient was treated with various conservative measures to include physical therapy for this he with no sustainable relief), and injections with temporary relief.  

The assessment conducted noted limited range of motion of the lumbar spine in all planes with positive Kemps test and pain during flexion along with tenderness over the lumbar paraspinals to palpation. Diagnostic imaging revealed moderate type I changes at L(lumbar)5-S(sacral)1. The physician recommended Intraosseous Nerve Ablation-Intracept procedure, which was denied as it was considered experimental or investigational.  

An appeal was submitted reiterating the patient's chronic low back pain and with notation that the intercept procedure has been found to be in objective biomarker when treating patients with complaints of low back pain. Multiple studies have been conducted and there are several peer-reviewed publications supporting the safety and efficacy of the basivertebral nerve ablation procedure.  

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

The interosseous nerve ablation (Intracept procedure) does not need to have final approval from the appropriate regulatory bodies for this diagnosis.

The interosseous nerve ablation (Intracept procedure) is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be as beneficial or more beneficial than any of the standard treatment/procedures for this patient.

Literature has noted that degenerative lumbar spine disorder (DLSD) is a ubiquitously occurring event that may be induced or accelerated by multiple factors such as from overuse, trauma, genetic predisposition, nutrition deficiency, and others. Evidence suggested that degenerative or damaged vertebral endplates are a significant cause of chronic low back pain and have not been adequately addressed by standard care. Although the diagnosis of vertebral genic pain is a relatively new clinical concept, there is a substantial body of basic science evidence supporting the vertebral endplates as a significant source of low back pain. Multiple studies have shown that treatment of this area has resulted in significant pain relief with intraosseous basivertebral nerve ablation demonstrating an excellent safety profile and significant improvement in pain, function, and quality of life. Based upon the provided information, it was determined that the patient was a suitable candidate for undergoing the proposed treatment.

The carrier's denial of pain management; outpatient procedure (Intraosseous Nerve Ablation-Intracept procedure) should be overturned.