Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. 
Treatment: Intracept Procedure-Intraosseous Ablation of the Basivertebral Nerve. 
The health plan denied the requested procedure. 
The health plan's determination is overturned. 

The patient is a male with chronic lower back pain in the setting of lumbar radiculopathy, spinal stenosis of the lumbar region with neurogenic claudication, sacroiliac joint dysfunction of the left side, vertebrogenic pain, lumbar spondylosis, and lumbar facet arthropathy. The patient denied injury or precipitating events. 
The magnetic resonance imaging (MRI) of the lumbar spine (non-contrast) revealed multilevel lumbar degenerative disc disease most advanced at (lumbar-sacral) L5-S1, small bulges at L2-L3 and L3-L4 and small disc herniation at L4-L5 without stenosis or nerve root compression, Grade 2 spondylolisthesis at L5-S1 secondary to spondylolysis of L5 with significant compression of both L5 nerve roots. Modic type 1 endplate changes adjacent to the L5-S1 disc. 
Treatment history includes rest, heat/ice, Aleve as needed (PRN), Tizanidine, Lidocaine patches (not effective), right L5-S1 transforaminal epidural steroid injections, right greater trochanteric bursa injections X 3 and right hip injections X 2 (no relief), physical therapy (helped improved range of motion but no relief of pain symptoms), bilateral L3, L4, L5 med and bilateral L4-L5 and L5-S1 facet injection with excellent relief. 
A progress note by anesthesiology, indicated that the patient rated his low back pain as 9/10 in intensity. The patient described his pain as intermittent and a combination of sharp and radiating (radiating to bilateral hips). The physical examination findings included decreased and painful lumbar spine range of motion (mild pain with extension and facet loading), negative Straight Leg Raise test bilaterally and Patrick test bilaterally. The treatment plan included medial branch block and facet injection at L3, L4, L5 bilaterally, Intracept procedure for Modic changes at L5-S1, and physical therapy. 
A progress note indicated that the patient reported 80% pain relief following bilateral L4-L5 and L5-S1 radiofrequency ablation (RFA). The patient rated his pain as 3/10. 
A progress note indicated that the patient reported 80% relief of his lower back pain following the RFA. It was indicated that the patient's pain remained stable since previous visits. However, the patient continued to complain of worsening pain in his lower back and bilateral hips with prolonged standing and walking.

This reviewer overturns, in whole, the health plan's determination regarding the proposed treatment. 

The proposed treatment Intracept procedure is likely to be more beneficial than any standard treatments for the insured's disabling condition. 
In this case, the patient failed more than six months of conservative treatment. The patient continued to complain of worsening pain in his lower back and bilateral hips with prolonged standing and walking. 

The Intracept procedure is indicated for this patient with more than six months of chronic low back pain with MRI-confirmed Type 1 Modic changes from L5-S1 and has not achieved sustained relief from at least six months of conservative treatment.
A review of peer-reviewed literature suggests that patients treated with radiofrequency ablation (RFA) of the basivertebral nerve for chronic lower back pain exhibited sustained clinical benefits in ODI (Owestry Disability Index) and VAS (Visual Analog Scale) and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of chronic lower back pain (CLBP). 

Therefore, based on the documentation reviewed and peer-reviewed literature, the request for the Intracept procedure is medically necessary.