Diagnosis: Low Back Pain
Treatment: Intracept Procedure (22899 & C9752)
The insurer denied the Intracept Procedure (22899 & C9752).
The denial is upheld.

The patient is a male with a history of chronic low back pain who has failed ESIs (epidural steroid injections), facet injections, and medications. His physical exam is positive for only tenderness to the low back. The Intracept procedure has been recommended. The procedure was initially denied, as the patient's insurance policy finds the procedure to be experimental. This decision has been appealed.

No, the health plan should not cover the Intracept procedure.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (United States Food and Drug Administration)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose.

However, despite the above, this patient has not failed or attempted sacro-iliac joint interventions, which is a common cause of axial low back pain. The patient's pain is axial; there is notation of facet arthropathy on the MRI (magnetic resonance imaging). Modic changes can be present in no vertebrogenic back pain. No physical exam is included in the submitted notes.

Therefore, while the Intracept procedure is an FDA-approved procedure that is not experimental/investigational, and is a reasonable option, it should be employed after all conventional and evidence-proven alternatives have failed. SI (sacroiliac) joint interventions have been shown to be effective in low back pain. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial than any standard treatment. Standard treatments have been shown to be effective.