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202304-161484
2023
Oxford
EPO
Central Nervous System/ Neuromuscular Disorder
Surgical Services
Medical necessity
Upheld
Case Summary
Diagnosis: Low Back Pain
Treatment: Nerve Treatment (ablation treatment)
The insurer denied: Nerve Treatment (ablation treatment)
The denial is Upheld
The patient is an adult male who has had low back pain for years. Past treatments include home exercise, weight loss, diclofenac, Advil, Aleve, facet rhizotomy, and epidural steroid injection. MRI (magnetic resonance imaging) of the lumbar spine shows multilevel degenerative changes, facet joint arthrosis, disc bulge, foraminal narrowing, and Modic type I changes at L4-5 (lumbar). The request for Intracept was denied coverage by the health plan, as it has not been shown to be effective, and was therefore deemed not medically necessary. The denial is being appealed.
The requested health service is not medically necessary.
Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the requested health service is not medically necessary.