Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraosseous ablation of the basivertebral nerve/Intracept. Findings:  The physician reviewer found that While the Intracept procedure has been shown to be effective for the treatment of vertebrogenic back pain without radicular features, there is a lack of evidence in current medical literature supporting its use in the setting of lumbar radiculopathy. In a prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain, Khalil and colleagues concluded that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three months in patients with chronic vertebrogenic related low back pain. Lorio and colleagues report that intraosseous basivertebral nerve ablation is indicated for patients with chronic non-radicular low back pain for at least six months, who have also failed six months of non-surgical management and that demonstrate Modic changes on at least one endplate on MRI. The authors concluded, The procedure is supported by level 1 evidence including two randomized controlled trials demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies. In this case, the patient has lumbar radiculopathy and reports low back pain radiating into the legs. The patient reported near complete relief post repeat lumbar medial branch block. The patient reported pain relief following lumbar epidural steroid injection. Given the patients diagnosis of lumbar radiculopathy and reported relief from lumbar epidural injections, the presence of Modic changes alone do not support the use of intraosseous ablation of the basivertebral nerve. Therefore, an Intracept procedure (intraosseous basivertebral nerve ablation) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested intraosseous ablation of the basivertebral nerve/Intracept  is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.