Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve ablation at L5 
and S1 vertebral bodies 
 
You asked the Plan to pre-approve Intracept intraosseous basivertebral nerve ablation. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 Intracept intraosseous basivertebral 
nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for vertebrogenic low back 
pain. The enrollee presented with continued mechanical low back pain. The leg pain is intermittent and sharp, with occasional numbness. Medications provide some relief, but the enrollee is not totally resolved in regard to 
the lumbar stiffness and pain when the enrollee is doing any weight-bearing activities. The magnetic resonance 
imaging (MRI) from May 27, 2022 was reviewed to show endplate changes at multiple levels from L1 to L4 at 
each disc and degenerative scoliosis spondylosis. The exam reveals tenderness of facet joints from L3-4, L4-5, 
and L5-S1 bilaterally. There is positive facet loading with extension. Strength, sensation, and deep tendon 
reflexes are intact. The gait is antalgic. However, the formal diagnostic imaging from May 7, 2022 did not 
corroborate Modic changes at the requested procedure level of L5/S1. Even on the provider review of the MRI, 
endplate changes were noted at multiple levels from L1-L4, not including the requested level of L5/S1. 
Additionally, there were/are multiple plausible pathologic sources of significant pain generation. The non-
radiating back pain, the noted pain-aggravating factors (weight bearing), pain-relieving factors (medications), 
along with the painful extension, and the intact neurologic exam were/are all non-specific to any pathologic 
entities. 
 
Overall, the documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept intraosseous basivertebral nerve ablation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Intracept intraosseous basivertebral nerve 
ablation at L5 and S1 vertebral bodies