Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain 
Treatment: 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is overturned. 

The patient is a female with a history of chronic low back and bilateral lower extremity pain who previously underwent conservative treatment, the only other option remaining is lumbar fusion. 

Yes, the health plan should cover the proposed treatment.

Yes, the requested health service or procedure is likely to be more beneficial than standard treatments.  

The patient is a female with a ten year history of axial low back pain. She has done physical therapy (PT), multiple injections, and radiofrequency ablation without much relief. She has taken opiate medications. Her only alternative remaining is a lumbar fusion, which she is trying to avoid.  

The Intercept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new FDA approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes.  

The patient is quite young, the alternatives, spinal fusion, do not have good long-term results in the literature.  Spinal fusion in young patients is typically not recommended and sought to be avoided.  It is a very invasive procedure with high morbidity and poor outcomes.  Most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.  Therefore, the options are limited.  Spinal cord stimulation is an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain.  Therefore the Intracept procedure is a reasonable option.  It is FDA approved.  Randomized studies are available.  Two year outcomes have proven high success.  It is not an intradiscal procedure which has not shown to have good results in the literature.  

Since there is no Medicare approved code (CPT code) for this procedure, the health plan has chosen a code for and intradiscal procedure however this does not accurately describes the requested procedure. 

Given that the alternatives do not show favorable outcomes in the literature, the requested Intracept procedure is medically necessary.