Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Basivertebral Low Back Pain
Treatment: Thermal destruction of intraosseous Basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept)
The insurer denied coverage for Thermal destruction of intraosseous Basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept).
The denial is overturned.

This case involves an adult with a history of low back pain that has been refractory to multiple treatments including ice/heat, epidural steroid injections, medial branch block injections, physical therapy, and sacroiliac joint injections. Magnetic resonance imaging (MRI) of the lumbar spine showed lumbar (L)5 - sacral (S)1 disc herniation deforming the thecal sac and abutting the proximal S1 nerve roots bilaterally with inferior extension posterior to the adjacent S1 superior endplate. There was interval development of prominent nonspecific bone marrow signal changes within the endplates adjacent to the L5-S1 disc space with etiology secondary to progressive reactive changes in conjunction with disc degeneration. At L4-5, there was disc herniation deforming the thecal sac and abutting the proximal L5 nerve roots bilaterally without interval change. The patient also had lumbar spine straightening.

The patient presented for an office visit. The patient rated the pain 7/10 or higher and endorsed that pain subsided with physical therapy and chiropractic care. Symptoms were exacerbated after another pregnancy and had been constant since then. At the time of the visit, the physician reviewed the patient's MRI and noted Modic changes at L5-S1. The patient was interested in the Intracept procedure given ongoing vertebrogenic low back pain with pain increased with flexion.

Scientific evidence in peer-reviewed literature supports a result of improvement and health outcome. Thermal destruction of interosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept). Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) is one of the, if not the best available treatment for this patient at this time.

Records confirmed that the patient was suffering from basivertebral low back pain with evidence of Modic changes noted on MRI at the L5-S1 level. The patient failed to respond to conventional treatment measures and remained symptomatic. Given that scientific evidence and peer-reviewed literature supports a result of improvement in health outcomes with notation that this treatment has been approved by the Food and Drug Administration, it has become mainstream treatment for patients with basivertebral low back pain. This treatment has been found to be as effective or more effective than standard treatment/procedures previously utilized to treat this condition.

Based upon the provided evidence in both clinical records and current peer-reviewed literature, the denial of coverage for thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) was not appropriate.

In summary, the carrier's denial of Thermal destruction of intraosseous Basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (Intracept) should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.