Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied: Intraosseous basivertebral nerve ablation 
The denial is: Upheld.

This is a patient with a diagnosis listed as low back pain. According to the records provided, the patient has a history of chronic back pain and failed conservative treatment and was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation).
The provider has submitted letters of appeal stating that the Intracept procedure is founded on 30 years of basic science research linking Modic changes to chronic back pain and feels that it has an excellent safety profile. The provider states that the patient's problem is chronic low back pain due to degenerative disc disease that has resulted in development of vertebrogenic pain identified by degenerative endplate changes (Modic) on magnetic resonance imaging (MRI). The provider states the patients chronic back pain began more than two years ago and he has tried multiple treatments including injections and medication management. Medications tried included Lyrica and Oxycodone. Pain is impacting activities of daily living such as bending, lifting and twisting. Nothing has provided sustained benefit. He had an MRI, demonstrating Modic type II changes at disc spaces (lumbar) L5 and (sacral) S1 and therefore, the provider feels that this is the source of the patient's chronic back pain. The provider requests reconsideration for proving this procedure.

A progress note indicated the patient was seen for evaluation of multiple pain generators. He was noted to have a history of brachial plexus effecting the left upper extremity and a history of thoracic outlet syndrome. He also has a history of low back pain likely secondary to annular tear at L4 - L5. He has been using Lyrica and Xtampza to manage his chronic pain. At times pain radiates into the bilateral lower extremities but not often. Physical examination revealed motor strength 5/5 in all extremities. No sensory deficits. Straight leg raise was negative bilaterally. Patrick's and Gaenslen's tests were negative bilaterally. Facet loading was negative bilaterally; palpation of the lumbar spine and left trapezius showed tenderness. It was recommended the patient undergo basivertebral nerve (BVN) ablation at L5 - S1.

The health plan's determination regarding the proposed health service or treatment is upheld.

No, there is no evidence that 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.
This treatment is not currently considered a 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. There is no evidence that this treatment would be likely to be more beneficial than other standard treatment options.