Appeal type: Experimental/Investigational
Decision: Upheld

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

This is a male patient whose diagnosis is low back pain. Records show the patient was recommended to undergo the Intracept procedure.
The provider states that the patient's low back pain began more than 4 months ago. The patient has tried other treatment including back brace, chiropractic, lumbar epidural injection, massage therapy, medications, and physical therapy. Medication has included ibuprofen, indomethacin, Medrol Dosepak, tramadol and Tylenol. Pain ranges from 7-9/10 and is affecting the patient's ability to perform activities of daily living. The provider noted the patient had a magnetic resonance imaging (MRI) scan demonstrating Modic changes at disc spaces lumbar (L) 3 - L4 and L4 - L5 and the provider believes that this is the source of the patient's chronic back pain.
The patient had complaints of chronic back pain that is progressively worse, rated at 7/10 and radiates to the right hip and thigh and down into the calves and feet. On physical examination, there was limited lumbar range of motion with pain. Lower extremity motor strength was 5/5 bilaterally. There was positive facet loading bilaterally, positive reverse straight leg raise bilaterally. It was recommended the patient undergo the Intracept procedure as well as undergoing lumbar epidural injection for radiculopathy. At issue is whether 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 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 back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). Although there were noted to be degenerative endplate changes on MRI, there are also multiple other findings that are likely significant pain generators including varying degrees of central canal stenosis, foraminal stenosis and lateral recess stenosis as well as facet joint hypertrophy. 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. 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.