Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain.
Treatment: 22899 - Unlisted procedure, spine (Intracept procedure).
The insurer denied the 22899 - Unlisted procedure, spine (Intracept procedure).
The denial is upheld.

The patient is a female with a history of low back pain. Past treatments include: intrathecal pain pump, physical therapy, sacroiliac joint injections, and trigger point injections, per the provider.  Medications include: oxycodone and Zanaflex without relief.  

The patient's pain on visual analogue scale (VAS) is eight out of ten (8/10) to ten out of ten (10/10).  Magnetic resonance image (MRI) shows vertebrogenic changes at L3 (third lumbar spine vertebra) and L4 (fourth lumbar spine vertebra), per the provider letter.  The patient's assessment includes: post-laminectomy syndrome, vertebrogenic pain, thoracic radiculitis, and long term prescription opioid use.  The patient is prescribed Prolia for a diagnosis of osteoporosis. The provider is requesting authorization for Sprint peripheral nerve stimulator (PNS) to the left 11th and 12th intercostal nerves.  The provider is also requesting authorization for Intracept for L3 (third lumbar spine vertebra) and L4 (fourth lumbar spine vertebra).   

Magnetic resonance image (MRI) of the lumbar spine demonstrates decompression from L1 (first lumbar spine vertebra) to S1 (first sacral vertebra) with interbody spinal fusion L3-4 (third and fourth lumbar spine vertebra) and partial resection of the spinous process L2-S1 (second lumbar spine vertebra to first sacral vertebra).  There is no mention of Modic Type I or Type II changes in this report.  Further, procedure history note shows T12-L3 (twelfth thoracic spine vertebra to third lumbar spine vertebra) fusion with subsequent surgeries for hardware removal, nerve spinal cord stimulator (SCS) trial with migrated wires, cervical radiofrequency procedures, thoracic epidurals, intercostal nerve blocks, trigger point injections, sacroiliac joint injection, hip injection, and removal of retained intrathecal (IT) pump catheter.  Office visit shows the patient being started on Levorphanol as well as considering seeing another provider for possible rib displacement.  

The requested coverage for 22899 unlisted procedure, spine (Intracept procedure) and C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance was not covered because it is experimental and investigational under the Health plan.  The Health plan only covers procedures that are recognized as safe and effective for the diagnosis or treatment of a condition based on clinical evidence published in the peer reviewed medical literature.

No, the health plan should not cover the proposed treatment for this patient.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.   


The patient does not meet inclusion and exclusion criteria in the current published studies.  As such, the Health plan should not cover the proposed treatment for this patient.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on type I or type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.   This patient does not meet inclusion and exclusion criteria in the current published studies.

The requested health service or treatment  is not more beneficial than any standard treatment for the patient's condition or disease.