Diagnosis: Low Back Pain
Treatment: Radiofrequency ablation
The insurer denied radiofrequency ablation.
The denial is upheld.

The patient is a female diagnosed with low back pain, vertebrogenic low back pain. The treating provider recommended the patient undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier as this procedure is considered not medical necessity. The provider is appealing this determination, which is the subject of this review. The subject under review is the medical necessity for the requested radiofrequency ablation.

The health plan's determination of medical necessity is upheld in whole.

The requested radiofrequency ablation is not medically necessary for this patient. The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). Magnetic resonance imaging (MRI) did show degenerative endplate marrow edema at the right lumbar (L)5 - sacral (S)1. However, it was also noted the patient has impingement of the exiting right L5 nerve root which could also be a likely pain generator.
This procedure is not the standard of care, as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary.