Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a patient who was diagnosed with spondylosis without (w/o) myelopathy or radiculopathy, lumbar region. The patient was recommended to undergo the intraosseous basivertebral nerve ablation (Intracept).

Magnetic resonance imaging (MRI) of the lumbar spine shows transitional, partially lumbarized sacral (S) 1; advanced degenerative changes lumbar (L) 4-L5 with large disc bulge and superimposed central disc herniation. There is encroachment if not impingement upon the descending L5 nerve roots in the lateral recesses bilaterally, greater on the right. There is also encroachment upon the neuroforaminal bilaterally with disc close to if not contacting the left L4 nerve root; minimal spinal stenosis; disc bulges and small central disc herniation L5/S1. It was noted there were Modic type I endplate changes at L4 -L5.
A progress report indicated the patient had complaints of chronic neck and back pain that radiates to the right hip and groin. The pain is improved with medications, heat, ice and stretching. The patient has tried physical therapy, chiropractic, massage and medications. Medial branch blocks provided only 20 percent (%) relief. The physical examination revealed positive straight leg raise bilaterally. The patient was recommended for the Intracept procedure and would continue on medications. At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There is no evidence to suggest that the proposed health service or treatment, nerve treatment in spine, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has chronic back pain with radicular symptoms and MRI shows multiple findings likely responsible for the patient's pain including disc herniations and encroachment on the L4 and L5 nerve roots. There is no evidence to suggest the Modic changes are responsible for the patient's pain. There is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required." This treatment is not currently considered 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. There is no evidence to suggest that the proposed health service or treatment nerve treatment in spine is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.