Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Intraosseous basivertebral nerve (BVN) ablation.
The insurer denied Intraosseous basivertebral nerve (BVN) ablation.  
The determination is upheld.

This is a female patient whose diagnosis was listed as low back pain. The records provided indicate that the patient was recommended to undergo the Intracept procedure, which was denied by the health plan. On appeal, the provider reported that the patient has chronic back pain that has failed conservative treatment including exercises, injections, lumbar epidural injections, medial branch blocks, medication management, physical therapy, and sacroiliac (SI) joint injections as well as chiropractic treatment. The patient has tried medications including ibuprofen, lidocaine patch, marijuana, tizanidine and Tylenol. The pain is impacting activities of daily living and nothing has provided relief. The pain is rated at 9/10. It was noted the patient had a magnetic resonance imaging (MRI) which the provider states showed Modic changes at disc spaces lumbar (L) 3, L4, L5 and sacral (S)1 (this was not noted on the actual magnetic resonance imaging (MRI) report however). The provider feels that this is the source of the patient's chronic back pain and requests reconsideration to perform the Intracept procedure.

At issue is whether intraosseous basivertebral nerve (BVN) ablation 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 that the proposed health service or treatment, 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.
The patient has a history of chronic back pain as well as SI joint pain. The patient has tried and failed conservative treatment including therapy, medication, and injections. The treating provider feels that the patient's pain is coming from Modic changes that were reportedly noted on MRI, however the official MRI report was submitted for review and does not mention any Modic changes, primarily noting a disc herniation and facet arthrosis. There was no mention of degenerative endplate changes consistent with Modic changes. The International Society for the Advancement of Spine Surgery's guideline on "Intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain" (Lorio et al., 2020) stated that intraosseous ablation of the BVN is a new procedure; its limitations included industry funding is a potential source of study bias for the available data reviewed, limited number of studies, short-term follow-up for the majority of studied patients, and unknown effect on the primary degenerative process." Per Becker et al.," Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." However, this is noted to be an industry sponsored study and does not demonstrate long term effects of the procedure beyond one year. There is insufficient evidence found in the peer-reviewed medical literature suggesting that the Intracept procedure is likely to be more beneficial than other standard treatments for this patient's condition.