Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is experimental.  
 
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 the Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that the enrollee was being treated for vertebrogenic low back pain; spondylosis of 
the lumbar region; and chronic pain. The enrollee presented with chronic pain secondary to multiple 
musculoskeletal problems. The enrollee has persistent axial lumbar pain and pain interferes with functional 
activities. The pain is aggravated with activity and prolonged postures and improved with activity modification. The pain is rated at 7/10. The exam reveals the surgical lesion is clean, dry, and without discharge with the 
staples intact from the spinal cord stimulator revision. The gait is slow and guarded. Segmental mobilization 
provokes pain over the L4-5 and L5-S1 segment. There is pain to palpation of the lateral mass on the right at 
L3-4, L4-5, and L5-S1. Pain with palpation is noted over the lower lumbar segments. There is significant 
involuntary muscle guarding in the lumbosacral region. General palpation reveals 15/18 positive tender points 
for fibromyalgia. There is decreased sensation over the lateral aspect of the left greater than right thigh. The 
lumbar range of motion is decreased with pain at the end range. However, the provided magnetic resonance 
imaging (MRI) from April 15, 2022 noted subtle signal abnormalities along the inferior endplate of L5 vertebra 
on short tau inversion recovery (STIR) imaging, decreased in conspicuity, no other areas of abnormal 
discogenic signal change. Modic changes are not corroborated by imaging at all of the requested levels per the 
formal diagnostic imaging report. Additionally, there were/are multiple plausible pathologic sources of 
significant pain generation. The aching pain across the low back, the noted pain-aggravating factors (activity 
and prolonged postures), pain-relieving factors (activity modification), the diminished and painful spinal 
motion (in all directions), and intact neurologic exam were/are all non-specific to any pathologic entities. 
Overall, documentation was/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 
requested Intracept intraosseous basivertebral nerve ablation at L4, L5, and S1 vertebral bodies, in this case, is 
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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.