Diagnosis: lower back pain
Treatment: Outpatient Intracept Procedure
The insurer has denied the Outpatient Intracept Procedure.
The health plan's determination is upheld.

The patient is a female with a history of chronic low back pain after a fall over 5 years ago. She was seen by Physical Medicine and Rehabilitation for a new pain clinic visit. Her pain was in the midline lumbosacral area and right paramidline with radiation to the bilateral gluteal regions and posterior thighs. It was worse with sitting and walking. She had transforaminal epidural steroid injections last year with 60-70 percent (%) relief of back and near resolution of her leg pain. She had two facet injections, one which was negative and three sacroiliac joint injections which one was very helpful. She had physical therapy a few years ago with a continued home exercise program. Her exam was normal. Her magnetic resonance imaging (MRI) was reviewed for a right paracentral protrusion contacting the traversing right sacral (S)1 nerve, Type II Modic changes at the inferior endplate of lumbar (L)5 at L5-S1. The assessment was vertebrogenic low back pain, and the Intracept procedure was recommended.

A lumbar MRI stated degenerative changes with anterior and posterior disc bulge osteophyte complexes, disc desiccation, and facet arthropathy. At L4-5 a posterior disc bulge making mild impression on the thecal sac, disc bulge, and facet arthropathy contributed to minimal right foraminal narrowing. At L5-S1 a broad based posterior disc bulge osteophyte complex making mild impression on the thecal sac, disc bulge osteophyte complex, and facet arthropathy contributed to mild left neural foraminal narrowing. There were mild endplate degenerative changes with mild T2 signal elevation involving the bone marrow adjacent to the L5-S1 endplates consistent with reactive edema associated with arthritic change.

At issue is whether outpatient Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
I uphold, in whole, the health plan's determination regarding the treatment.

The proposed treatment is not likely to be more beneficial than any standard treatment for the patient's condition.

She has low back and bilateral thigh and posterior leg pain with multiple pathologies in the lumbar spine at L4-5 and L5-S1 to include disc protrusions and facet arthropathy as well having positive responses to epidural steroid injections and one sacroiliac joint injection. It is unclear if her back pain is coming from the basivertebral nerve. Studies have specifically excluded patients with radicular pain or significant facet arthropathy. Therefore, the procedure may not be beneficial and would be considered experimental/investigational. It is unknown if there are long-terms adverse risks with the requested surgery over standard services or treatment.