Vertebrogenic Low Back Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure. In a randomized control trial evaluating the effectiveness of intraosseous radiofrequency ablation of the basivertebral nerve to standard treatment of chronic low back pain in a specific subgroup of patients suspected to have vertebrogenic related symptomatology, researchers found clear statistical superiority for all primary and secondary patient-reported outcome measures in the radiofrequency ablation arm compared with the standard care arm. The authors noted statistically significant improvements in the Oswestry Disability Index (ODI) scores and visual analogue scores (VAS) in the treatment arm compared to the arm receiving standard care.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Intracept procedure thermal destruction of intraosseous basivertebral nerve (BVN), inclusive of all imaging. A randomized control trial compared the effectiveness of intraosseous radiofrequency (RF) ablation of the BVN (Intracept procedure) to standard treatment for patients with chronic low back pain suspected to have vertebrogenic related symptomatology. The study showed clear statistical superiority of RF ablation over standard treatment for all primary and secondary patient-reported outcome measures. The authors observed that there were statistically significant improvements in patients’ Oswestry Disability Index (ODI) scores and visual analog scale (VAS) with RF ablation compared to standard treatment.

Where the denial was upheld

Findings: The physician reviewer found that an enrollee has requested authorization and coverage for the Intercept procedure. In this case, the patient is being treated for vertebrogenic low back pain. In notes, the patient reported sacroiliac joint pain, greater on the left than on the right, that worsened with prolonged sitting. He reported vertebrogenic pain with bending forward. On examination, there was pain with range of motion in all planes, most with flexion, and left-sided sacroiliac joint tenderness. Flexion Abduction External Rotation (FABER), iliac compression, and Gaenslen’s tests were positive on the left. The U.S.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Intracept procedure. In this case, the patient is being treated for chronic vertebrogenic low back pain, intervertebral disc degeneration of the lumbar region, and intervertebral disc degeneration of the lumbosacral region. In notes, the patient reported neck and back pain, 90% in the back and 10% in the legs. The patient rated her pain at seven out of ten. A lumbar spinal examination reveals tenderness to palpation over the bilateral facet joints and sacroiliac joints, with a limited range of motion secondary to pain and intact sensation, strength, and reflexes. The U.S.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving vertebrogenic low back pain, then check the rights and deadlines that apply to your plan.