Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of the intraosseous basivertebral 
nerve, including all imaging guidance first two vertebral bodies lumbar or sacral and thermal destruction of the 
intraosseous basivertebral nerve, including all imaging guidance. 
 
You asked the Plan to pre-approve thermal destruction of the intraosseous basivertebral nerve, including all 
imaging guidance first two vertebral bodies lumbar or sacral and thermal destruction of the intraosseous 
basivertebral nerve, including all imaging guidance. The Plan denied your request. The Plan says the requested 
services are experimental and unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve thermal destruction of the intraosseous 
basivertebral nerve, including all imaging guidance first two vertebral bodies lumbar or sacral and thermal destruction of the intraosseous basivertebral nerve, including all imaging guidance. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 69-year-old male with chronic low back pain due to degenerative disc disease 
(DDD). He has been treated with medical therapy, physical therapy (PT), bracing, chiropractic, acupuncture, 
sacroiliac joint (SIJ) injections and medial branch blocks. His provider has recommended the Intracept 
procedure. For individuals who have vertebrogenic pain who receive ablation of basivertebral nerves, the 
evidence includes two randomized controlled trials (RCT) (SMART and INTRACEPT trials). Relevant 
outcomes are symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 
12 months, 73% of patients crossed over to the active treatment group and therefore long-term comparative 
data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-
up. The evidence is insufficient to determine that the technology results in an improvement in the net health 
outcome. The review has determined that the services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of the intraosseous basivertebral nerve, including all 
imaging guidance first two vertebral bodies lumbar or sacral and thermal destruction of the intraosseous 
basivertebral nerve, including all imaging guidance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of the intraosseous basivertebral nerve, including all imaging 
guidance first two vertebral bodies lumbar or sacral and thermal destruction of the intraosseous basivertebral 
nerve, including all imaging guidance.