Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back Pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient who was diagnosed with low back pain. 
Letters of appeal submitted a state that the patient's primary problem is chronic low back pain due to degenerative disc disease that has resulted in the development of vertebrogenic pain identified by degenerative endplate (Modic) on magnetic resonance imaging (MRI). The provider notes that the patient has tried multiple treatments including activity modification, acupuncture, chiropractic, heat, ice, home exercises, lumbar federal steroid injections, medial branch blocks, medication management, physical therapy, and radiofrequency ablations. Medications have included gabapentin and naproxen. The pain is rated at 6/10 and affects the patient's ability to perform bending, lifting, and sitting. The provider noted the patient had a magnetic resonance imaging (MRI) scan performed demonstrating Modic type II changes at disc spaces lumbar (L) 5 - sacral (S) 1 and the provider believes this is causing the patient's chronic back pain.
There is a letter of appeal from the patient stating that the patient has been recommended to undergo the Intracept procedure by a provider who stated it would be far less painful and invasive than the procedure that his office would do which would include performing a discogram followed by spinal fusion. The patient reports low back pain is preventing him from having any ability to lead an active life. The patient cannot run, ride a bike, carry anything above lightweight, and has low back pain from sitting, standing, or lying down for an extended period. The patient believes that the benefits of the Intracept procedure far outweigh the risks, as well as the risks of a spinal fusion.
The patient presented with complaints of pain in the lower back and leg. The patient had lumbar medial branch blocks with 10 percent (%) pain reduction. The current treatment includes anti-inflammatory medication and anticonvulsants with naproxen and gabapentin providing temporary relief. The physical examination revealed paraspinal muscle tenderness to palpation bilaterally and limited lumbar range of motion. Negative facet loading and negative straight leg raise. Strength and sensation are intact in the lower extremities. It was recommended the patient undergo the Intracept procedure and this is under review.
The proposed health service or treatment Intraosseous Basivertebral Nerve Ablation (BVN) Procedure 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 patient is noted to have a history of chronic low back and lower extremity symptoms. The provider believes that the patient's back pain is coming from Modic changes, although the MRI report provided shows multilevel disc herniations with multilevel nerve root impingement and annular fissures, likely pain generators. There is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.