Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal -Back Pain. 
Treatment: Surgical Services (All). 

The insurer denied Intracept Procedure. 
The denial is upheld. 

This is a female patient diagnosed with spondylosis without (w/o) myelopathy or radiculopathy, lumbar region. The patient is noted to have ongoing chronic back pain and the provider recommended the patient undergo Intraosseous basivertebral nerve ablation. 
There is a letter of appeal from the provider stating that intraosseous ablation of the basivertebral nerve is an innovative procedure to address chronic low back pain identified from Modic changes. The provider reports that the patient has a history of low back pain beginning over one year ago and has tried multiple treatments including acupuncture, chiropractic care, home exercises, injections, medial branch blocks, medication management, physical therapy, radiofrequency ablation and transforaminal epidural steroid injections. 
A magnetic resonance imaging (MRI) scan of lumbar spine revealed convex left curvature with straightening of the upper lordosis, multiple Schmorl's nodes and Modic type I endplate changes L2-L3 and L5 - S1 as well as Modic type 2 endplate changes at L3 - L4 and L4 - L5. There is L1 - L2 facet arthropathy, L2-L3 minor retrolisthesis, bulge and facet arthrosis with inferior foraminal stenosis, L3 - L4 disc bulge and facet arthrosis with inferior foraminal stenosis, L4 - L5 bulge and facet arthrosis, L5 - S1 bulge and facet arthrosis, left lateral herniation and central annular fissure.
At issue is whether the proposed health service or treatment Intracept Procedure is likely to be more beneficial than any standard treatment for this patient. 

The health plan's determination regarding the proposed health services or treatment is upheld in whole. 

The proposed health service or treatment Intracept 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.
Per 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. If approved despite non-recommendation, there should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and S1 on magnetic resonance imaging." Records indicate the patient has a history of chronic back pain and while the provider states that the patient's pain is coming from Modic changes at L5 - S1, the MRI shows multiple findings at every level likely responsible for the patient's symptoms including multiple Schmorl's nodes, Modic changes at L2-L3, L5 - S-1, L3 - L4 and L4 - L5. Facet arthropathy is noted at multiple levels, there is foraminal stenosis, multilevel disc bulges, L5 - S1 disc herniation and central annular fissure. There is no evidence to suggest that Modic changes at L5 - S1 are responsible for the patient's symptoms. While it is noted the patient has tried and failed extensive conservative treatment as well as injections, the requested procedure is considered experimental and investigational and there is no evidence to suggest this procedure would be beneficial over that of traditional treatment options. 

Therefore, the proposed health service or treatment Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for this patient.