Diagnosis: Low Back Pain
Treatment: Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance
The insurer denied the Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance.
The denial is upheld.

The patient is a male with low back pain. He had a basketball injury years ago. He has had multiple bouts of PT (physical therapy) and facet blocks, which provided short-term relief. He can stand for about 45 minutes. He denies any numbness or tingling. His pain is exacerbated by prolonged standing or jumping. His physical exam reveals mild back tenderness in lumbosacral spine with percussion.

The patient's MRI (magnetic resonance imaging) lumbar spine shows L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra) disc desiccation with type I and type II modic changes. There is also fluid in the facets consistent with facet degeneration.

The patient's provider recommends L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra) Intracept procedure.

No, the health plan should not cover the requested health service.

This patient has chronic low back pain with tenderness in the lumbar spine and temporary relief with facet injections. His pain is worse with standing and not with flexion at the waist or with sitting. Therefore, the patient is not evidenced to have discogenic pain. Since he had relief with facet blocks even temporarily, the facets are a likely source of his pain, and then the Intracept may not provide any benefit. There was not a thorough physical examination of the spine documented that supports discogenic related pain.

The Intracept procedure has been shown to be safe and effective treatment in properly selected patients, but this patient is not evidenced to be an ideal candidate, based on the information provided.

Since the patient had temporary relief with facet blocks, facet ablation may provide more relief. Also, the patient is not evidenced to have symptoms consistent with discogenic pain, so the Intracept may not be helpful. In addition, more conservative treatments can always be attempted with minimal risk to the patient.