Is the Intracept (basivertebral nerve ablation) procedure medically necessary for a patient with chronic low back pain, limited range of motion, and failed conservative treatments, including physical therapy and interventional procedures, despite having decreased disc height, disc bulge, and facet arthropathy at L5-S1?

Medical Necessity Determination: Basivertebral Nerve Ablation (Intracept) for Chronic Low Back Pain

Primary Recommendation

The Intracept procedure for basivertebral nerve ablation is NOT medically necessary for this patient based on the most recent and highest quality guideline evidence, which provides a strong recommendation AGAINST this procedure. 1

Rationale Based on Current Evidence Hierarchy

Highest Quality Guideline Evidence (2025 BMJ)

The 2025 BMJ clinical practice guideline—the most recent and highest quality evidence available—provides strong recommendations AGAINST basivertebral nerve ablation for chronic low back pain. 1 This guideline explicitly states that all or nearly all well-informed people would likely not want this intervention based on the current evidence. 1

The BMJ guideline notes that the 2022 American Society of Pain and Neuroscience (ASPN) guideline provided a "strong recommendation in favour of basivertebral nerve ablation for chronic back pain," but the BMJ panel—using more rigorous evidence-based methodology—reached the opposite conclusion. 1 This represents a critical divergence in guideline recommendations that must be addressed.

Why the BMJ Guideline Takes Precedence

• Methodological superiority: The BMJ guideline explicitly criticizes consensus-based guidelines (like ASPN) as "more likely to produce recommendations that violate the principles of evidence-based medicine." 1

• Patient-centered approach: The BMJ guideline involved patient partners and considered patients' values and preferences, which consensus guidelines typically fail to do. 1

• Explicit evidence evaluation: The BMJ guideline describes an explicit process to evaluate the overall certainty of evidence, unlike many interventional procedure guidelines. 1

Corporate Payor Board (CPB) Determination Alignment

The CPB policy correctly identifies basivertebral nerve ablation as "unproven because of insufficient evidence of their effectiveness" for low back pain treatment. 1 This determination aligns with the highest quality guideline evidence and should be upheld.

Analysis of Supporting Evidence Claims

Limited Research Evidence Quality

While the American Society of Pain and Neuroscience published "best practice guidelines" in 2022 claiming Level A evidence for basivertebral nerve ablation 2, this represents a consensus-based guideline that conflicts with evidence-based methodology. 1

The 2021 systematic review found only "moderate-quality evidence" with significant limitations: 3

• Industry funding bias concerns
• Highly selected patient populations (Modic type 1 or 2 changes required)
• Lack of true control groups due to high crossover rates
• Very few long-term studies
• Need for non-industry funded research 3

A 2022 scoping review identified critical gaps: 4

• Very specific chronic pain populations utilized, leaving many with chronic low back pain ineligible
• Lack of demographic diversity
• Absence of true control groups
• Predominantly industry-led funding creating potential bias 4

Patient-Specific Criteria Analysis

Why This Patient Does NOT Meet Criteria

Imaging findings are non-specific: The patient has "decreased disc height, disc bulge and vertebral endplate spurring, facet arthropathy" at L5-S1. [@question@] These are common degenerative findings that do not specifically indicate vertebrogenic pain as the primary pain generator.

No documentation of Modic changes: The available research consistently requires Modic type 1 or 2 endplate changes on MRI as a selection criterion for basivertebral nerve ablation. 3, 4 The clinical documentation provided does not mention Modic changes, which are essential for patient selection according to the limited supporting evidence.

Alternative pain generators present: The patient has facet arthropathy and neuroforaminal narrowing, suggesting multiple potential pain sources. [@question@] The presence of "some sciatic type of pains into the lower extremities" indicates radicular involvement, which contradicts the pure axial pain pattern typically required for basivertebral nerve ablation candidacy. 3

Inadequate diagnostic workup: There is no documentation of diagnostic medial branch blocks or other procedures to rule out facet-mediated pain before considering this novel intervention. 5

Risk-Benefit Analysis

Potential Harms

• Small risk of moderate to serious harms including deep infection and temporary altered level of consciousness 1
• Very small risk of catastrophic harms 1
• Financial burden without proven benefit 1
• Delay of potentially more effective treatments 1

Uncertain Benefits

• The procedure remains in "early stages of adoption and integration into spine care pathways" 2
• Success rates of 45-63% for ≥50% pain reduction at 3 months in highly selected research populations 3
• No long-term outcome data beyond research settings 4

Alternative Management Pathway

Recommended Next Steps

Complete diagnostic evaluation for facet-mediated pain: Given the patient's facet arthropathy and pain with extension, diagnostic medial branch blocks should be considered first. 5 Two positive diagnostic blocks with >50-80% pain relief are required before any ablative procedure. 5

Consider conventional radiofrequency ablation if facet pain confirmed: If diagnostic blocks are positive, conventional radiofrequency ablation of medial branch nerves has stronger evidence (though still mixed) compared to basivertebral nerve ablation. 6, 7

Obtain MRI assessment for Modic changes: If basivertebral nerve ablation is to be reconsidered in the future, specific documentation of Modic type 1 or 2 endplate changes is mandatory based on all available research. 3, 4

Common Pitfalls to Avoid

• Do not proceed with novel interventions lacking high-quality evidence when the most recent evidence-based guidelines recommend against them 1
• Do not assume all degenerative changes on imaging indicate candidacy for specific interventional procedures 3
• Do not bypass diagnostic algorithms that could identify more established treatment targets 5
• Recognize industry influence in emerging procedure adoption and prioritize independent, evidence-based guidelines 1, 4

Final Determination

CRITERIA NOT MET: The Intracept procedure for basivertebral nerve ablation is not medically necessary for this patient based on:

1. Strong recommendation AGAINST from the highest quality 2025 BMJ guideline 1
2. CPB determination of "unproven" status is appropriate 1
3. Absence of required diagnostic criteria (Modic changes) 3
4. Presence of alternative pain generators requiring evaluation 5
5. Insufficient high-quality, independent evidence to override guideline recommendations 4, 3