Intracept Procedure denials in California external review
In the California DMHC record, independent physician reviewers decided 107 published external-review cases involving Intracept Procedureand overturned the plan’s denial in 43.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Chronic Low Back Pain | 32 | 34.4% |
| Vertebrogenic Low Back Pain | 16 | 43.8% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 94 | 44.7% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 13 | 38.5% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure (thermal destruction of intraosseous nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral). 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: 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.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure at L4-L5 and L5-S1. The U.S. Food and Drug Administration (FDA) approves the use of the Intracept Intraosseous Nerve Ablation System in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain that has not responded to at least six months of conservative care, and is also accompanied by features consistent with type 1 or type 2 Modic changes on magnetic resonance imaging (MRI), such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals, and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signal…
Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the Intracept procedure for lower back pain.The U.S. Food and Drug Administration (FDA) approves the use of the Intracept Intraosseous Nerve Ablation System in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain that has not responded to at least six months of conservative care and is also accompanied by features consistent with Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI), such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hype…
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Intracept Procedure, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY