Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous nerve ablation 
The health plan denied the requested intraosseous nerve ablation as experimental/investigational.
The health plan's determination is upheld.

This is a female patient. The patient is diagnosed with low back pain. Records indicate the patient was recommended to undergo the intracept the procedure.
A magnetic resonance imaging (MRI) of lumbar spine revealed minimal retrolisthesis at (lumbar) L1 - L2, spondylosis and facet arthrosis, a small left-sided disc protrusion (thoracic) T11-T12 which may encourage upon the left T12 nerve root, a small left lateral recess disc protrusion (lumbar) L2-L3, new compared to a prior MRI, a small left criminal disc protrusion of L3 - L4 without compression of the exiting nerve, unchanged since a prior study. The patient was noted to have Modic type I (degenerative endplate and marrow) alterations visualized at L4 - L5 and Modic II signal alterations at (lumbar/sacral) L5 - S1.
In a progress note, the patient had complaints of neuropathy in the bilateral lower extremities that is not thought to be due to the lumbar spine. The patient uses Gabapentin prescribed by neurology. The patient has complaints of low back pain with sitting and leaning forward and it is generally constant and located at the lumbosacral junction, rated at 9-10/10. Conservative treatments over the years have included epidural steroid injections and medial branch blocks without significant relief. She is participating in a home exercise program and has done so for the past eight weeks. She has had physical therapy and chiropractic in the past and has a history of gastric ulcer and cannot take non-steroidal anti-inflammatory drugs (NSAIDs). Tylenol has been ineffective. Physical examination revealed normal range of motion, motor strength 5/5 in all extremities, negative Hoffmans and Spurling's maneuver, no sensory deficits, straight leg raise negative bilaterally, Patrick's and Gaenslen's. The only abnormal finding was a positive facet joint loading sign. The plan was to perform the intracept procedure at L4, L5, S1, consider offering an epidural steroid injection for severe pain right now and increasing Gabapentin.
At issue is whether the proposed treatment of an intraosseous 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.

I uphold, in whole, the health plan's determination of medical necessity.

No, there is no evidence that the proposed health service or treatment of an intraosseous 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 patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The patient was noted to have Modic type I degenerative endplate alterations visualized at L4 - L5 and Modic II degenerative endplate signal alterations at L5 - S1. 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). This procedure remains experimental and investigational, as 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. 

Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary. There is no evidence that the proposed health service or treatment of an intraosseous 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.