Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain. 

Treatment: 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The insurer denied coverage for 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The denial is upheld. 

The patient is a female with a history of chronic low back pain. She reports low back pain which is rated 1/10 (on a pain scale of 1-10) at rest and 10/10 with activity. She has associated numbness and tingling in the left leg towards the knee. She had failed chiropractic care, physical therapy and meloxicam. Her past medical history is positive for spondylolisthesis. 

There is sufficient scientific evidenced in peer-reviewed literature to support improvements in health outcomes for patients with vertebrogenic pain per the International Society for the Advancement of Spine Surgery. (1) 

The procedure is FDA (food and drug administration) approved and states that the Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency (RF) generators for the ablation of basivertebral nerves of the L (lumbar) 3 through S (sacral) 1 vertebrae for the relief of chronic low back pain of at least 6 months duration that has not responded to at least six months of conservative care and is also accompanied by either Type 1 (bone marrow oedema and inflammation) or Type 2 (marrow ischemia) Modic changes on an MRI (magnetic resonance imaging). (2) 

Based on the documentation, she complains of low back and left leg pain to the knee. Her exam is showing weakness in the bilateral hip flexors 4/5 and a positive straight leg raise on the left which would indicate a radiculopathy. Her lumbar MRI shows a spondylolisthesis at L4-5 with degenerative disc changes at L4-5 and L5-S1. The MRI does not state that she has any Modic changes of the endplates which would be needed in order to meet criteria. Furthermore, there is no flexion/extension x-ray to determine if she has mobility at the L4-5 level that would cause back pain. It appears she has a radicular pain as well as axial pain that may not be addressed with this procedure and she would not clearly benefit from Intracept. She does not meet the indications for the Intracept procedure as noted by ISASS (International Society for the Advancement of Spine Surgery) guidelines: Intraosseous ablation of the BVN (basivertebral nerve) from the L3 through S1 vertebrae may be considered medically indicated for individuals with chronic low back pain when all of the following criteria are met: 
- Chronic axial low back pain (CLBP) of at least 6 months duration; and Failure to respond to at least 6 months of non-surgical management and MRI demonstrated Modic Type 1 or 2 changes in at least one vertebral endplate, at one or more levels from L3 to S1. (1) Is Intracept Procedure the best available treatment for this patient at this time?
No. Based on the medical records, it does not appear that the Intracept procedure is the best available treatment at this time due to her back and radicular pain and her MRI not showing Modic changes and a spondylolisthesis where it is unknown if this is unstable. Are the adverse risks increased over standard treatment/services? The adverse risks to this procedure are minimal compared to a lumbar fusion, and more than conventional therapies. The Intracept procedure has an excellent safety profile. (1) 

The carrier's denial of 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum should be upheld.  It is not more beneficial than any other standard treatments.