Experience with Intracept.

[bedrock]

Define “need” it.

Easy.

Axial, bilateral, LBP significantly limiting function, in a patient that failed PT, MBB/RFA, NSAIDs, tramadol, lyrica/gabapentin
They have worse pain with lumbar flexion/prolonged sitting, and often feel they have to frequently change sitting positions for relief.

And they have modic changes on lumbar spine MRI.

Both of my patients this week met those criteria.

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[MitchLevi]

I referred a pt out recently for this procedure. Insurance denied bc he hadn't ever had an SIJ CSI. Unreal.

 

[Ducttape]

Define “need” it.

$omeone who ha$ modic change$ on imaging?

i agree, hard to find patients. in addition, hard for me to tell them "oh im going to start doing this procedure, you will be one of the first"

 

[NJPAIN]

I just had a patient denied because she didn’t have 3 sessions with psych

 

[Taus]

I just had a patient denied because she didn’t have 3 sessions with psych

Presumably Cigna? They 100% require it on their policy. Send them to advantage point behavioral, telehealth.

 

[lobelsteve]

I just had a patient denied because she didn’t have 3 sessions with psych

If you told me my Modic changes were all in my head....

I'd be...

 

[NJPAIN]

Presumably Cigna? They 100% require it on their policy. Send them to advantage point behavioral, telehealth.

Exactly. I’m glad that you know that because our prior authorization department does not look at coverage policies before or after submitting claims so they had no clue. They also don’t submit or track appeals.

Do you use the manufacturer’s prior authorization service or do you it in-house?

 

[Taus]

Exactly. I’m glad that you know that because our prior authorization department does not look at coverage policies before or after submitting claims so they had no clue. They also don’t submit or track appeals.

Do you use the manufacturer’s prior authorization service or do you it in-house?

100% manufacturers prior auth process. Not feasible to do this procedure without, given all the appeals etc. needed to get them approved.

 

[BobBarker]

Relievant does a great job with the prior auth process. Definitely rec using them.

 

[NJPAIN]

Relievant does a great job with the prior auth process. Definitely rec using them.

You were previously hospital based, correct? Did you use the manufacturers prior authorization service in that setting as well?

I’m going to start another thread on the topic of manufacturer’s prior auth services. My institution is fighting me on this as it pertains to: Sprint, ReActiv8 and INTRACEPT. Meanwhile, we cannot get a non- government payer case approved using our internal PA department. Based upon their experience at the “mothership” they claim that trying to use the manufacturer’s service was “the worst decision we ever made” and they refuse to consider it for PNS and BVN. If I can get some testimonials to the contrary, perhaps I can convince them that it is the best route to take.

 

[Tboned]

You were previously hospital based, correct? Did you use the manufacturers prior authorization service in that setting as well?

I’m going to start another thread on the topic of manufacturer’s prior auth services. My institution is fighting me on this as it pertains to: Sprint, ReActiv8 and INTRACEPT. Meanwhile, we cannot get a non- government payer case approved using our internal PA department. Based upon their experience at the “mothership” they claim that trying to use the manufacturer’s service was “the worst decision we ever made” and they refuse to consider it for PNS and BVN. If I can get some testimonials to the contrary, perhaps I can convince them that it is the best route to take.

Relievant’s prior auth team basically does everything for you so. My assistant uploads some clinical documents into the prior auth portal and they do the leg work. I think it’s the best thing since sliced bread. I would not trust our group’s regular prior auth team to handle Intracept cases. It would create a huge amount of extra work for myself because I would be constantly having to hold their hand and deals with the constant denials/appeals.

 

[NJPAIN]

Relievant’s prior auth team basically does everything for you so. My assistant uploads some clinical documents into the prior auth portal and they do the leg work. I think it’s the best thing since sliced bread. I would not trust our group’s regular prior auth team to handle Intracept cases. It would create a huge amount of extra work for myself because I would be constantly having to hold their hand and deals with the constant denials/appeals.

That is exactly our situation with regard to INTRACEPT, Reactiv8 and SPRINT. PA submits and gets denial. PA contacts me to submit appeal and then wants ME to let them know the outcome. They expect the care team to deal with that. Generally, if appeal is denied, the case is dead. If there is the possibility to submit to IRO, our PA department doesn’t get involved. Previously, in my own private practice, I used every manufacturer’s PA service .

 

[Taus]

This procedure would have been dead in without their prior auth team…..

 

[BobBarker]

The hospital refused and nothing besides traditional medicare would get scheduled.

 

[Taus]

The hospital refused and nothing besides traditional medicare would get scheduled.

Their loss on the sos….. or perhaps was before commercial carriers started to come on board and/or their contracts did not have favorable language with new codes to cover costs and turn a profit

 

[RoloTomassi]

With Relievant PA, my staff inputs pt records into portal the day I order (except when waiting on rad report addendum, ODI, CBT records, etc). Relievant does the rest.

 

[BobBarker]

I really think that one of the reasons Boston bought Relievant was to use their portal/auth process to save Vertiflex.

 

[MitchLevi]

i agree, hard to find patients. in addition, hard for me to tell them "oh im going to start doing this procedure, you will be one of the first"

This is my issue. How do you form a line?2

I can't get trained until I have 5 patients waiting, but I can't get 5 patients waiting if I'm not trained.

 

[RoloTomassi]

After you identify 5 patients tell them it's a lengthy process that you'll get started (portal input) but in the meantime continue to treat as you have been. Should buy you time to go to training session. Even with a fast approval, there's labs, EKG, clearance for anesthesia for most people, OR availability, etc. that buys you more time.

I wouldn't advertise you're their first case, but if asked, most people don't mind if it's a new procedure--no one's done more than a few around you likely. Tell them it's nearly identical to a kypho, which you've done, and if they trust you to do everything else thus far, I'm sure they'll trust you with this. Show them the safety profile, chances of relief, durability data, and they're usually sold.

 

[NJPAIN]

This is my issue. How do you form a line?2

I can't get trained until I have 5 patients waiting, but I can't get 5 patients waiting if I'm not trained.

It’s the same crap started by Abbott for DRG a few years back. It caused such an uproar that if I remember correctly Abbott’s medical director published a statement or letter defending their position citing patient safety concerns with low volume implanters. While that might be a concern, most believed the real issue was ROI for their training cost. Since then, many manufacturers are doing the same thing, citing the same reasons. I’ve even had a company refuse to send a rep for an individual case telling me that I need to “stack” the cases. Twenty years ago none of this would fly. You train me, if your product is good I will use it. If not, too bad. If I need you to come for one case, you come or we never call you again. Now, plenty of docs will pick 5 patients for the procedure regardless of the lack of indications, just to get trained on the latest gadget. It’s an overall change in the culture of the field.

 

[Tboned]

This is my issue. How do you form a line?2

I can't get trained until I have 5 patients waiting, but I can't get 5 patients waiting if I'm not trained.

I was trained “on the job” during fellowship and with the number of cases I had under my belt I was granted a “training certificate” and was able to bypass the formal training process.

I can see how lining up 5 patients in order to do the training course would be frustrating and difficult. Tough situation. I feel fortunate I did not have to go that route.

 

[ErrantWhatever]

I had 5 patients in the prior auth process and one got it very quickly. Led to some awkward convos, as the very nice patient was also informed of the decision and was confused why we weren’t scheduling immediately.

Their requirement for 5 patients is just unrealistic.

I also have been searching for patients for 6 months and have found 6-7 that I believe are clinically appropriate for this procedure. The presence of Modic changes without flexion-based axial lbp is common in my clinic.

 

[NJPAIN]

Again, it’s a cultural issue. I doubt that surgeons put up with this BS. Train first, then look for patients. In pain medicine it’s all about exclusivity and having the ability to do something the next guy cannot. After all, do you see spine surgeons on LinkedIn holding up a box, standing next to a rep in order to claim being the FIRST to put in a particular implant in their state? I don’t think so. We need to grow up, stop thinking only as individuals, grow some gonads and tell the manufacturers we won’t put up with these insane requirements.

 

[Taus]

Just tell patients you are waiting for the insurance contracts to get set up at your surgery center/hospital. This happens when a brand new procedure code has to be added.

 

[bedrock]

Just tell patients you are waiting for the insurance contracts to get set up at your surgery center/hospital. This happens when a brand new procedure code has to be added.

That is a good idea.

How did you handle discussing with patients that this was your first few times doing Intracept?

 

[Taus]

That is a good idea.

How did you handle discussing with patients that this was your first few times doing Intracept?

Explained it’s not a new skill for me. An extension of what I was trained to do in fellowship (ie kypho). Pedicle access is same, just new tools to reach this unique target are a bit different. Something like that.

 

[Centurion38]

I was trained “on the job” during fellowship and with the number of cases I had under my belt I was granted a “training certificate” and was able to bypass the formal training process.

I can see how lining up 5 patients in order to do the training course would be frustrating and difficult. Tough situation. I feel fortunate I did not have to go that route.

Tried to send you a PM but for some reason was not allowed. I am a pain fellowship PD who does a lot of Intracept.

I'd like details on how you got a "training certificate" from your fellowship training so that I can take this to Relievant, because they are giving my fellows the usual BS dog and pony show about having 5 cases in the portal before training etc. even though these guys have done double digit Intracept cases AND will graduate with 10-15 Kyphoplasties each. They know how to traverse a pedicle.

Please help me out so I can help my fellows. Happy to chat by email or cell. Send me a pm.

Thanks

 

[MitchLevi]

How many fractures have yall seen at the levels you previously treated?

 

[Taus]

Zero. Over 100 cases.

For my patients with known osteopenia I have counseled them extensively on the risk and rec much stricter physical restrictions than usual for about a month.

 

[bedrock]

On another thread someone posted about doing intracept with IV sedation only.

Anyone do that? What are your recommendations and advice?

It would make my life easier if I didn’t have to deal with anesthesia, but also don’t want to get in over my head.

 

[RoloTomassi]

How many fractures have yall seen at the levels you previously treated?

None

On another thread someone posted about doing intracept with IV sedation only.

Anyone do that? What are your recommendations and advice?

1. Level headed pt that tolerates procedure pain well
2. Since you're just starting, limit to 1 level cases till you're fast, comfortable with the tools, troubleshooting
3. Numb the track and periosteum well. Time the IV push before going through VB cortex and before crossing midline, the two most painful times. The burn is not that bad, first few minutes is worst.
4. Have hand drill ready, less painful than hammering hard bone.
5. Have reversal agents ready, sometimes cases get long and patient doesn't tolerate as well as you had hoped, so sedation doses can get high.
6. Try to be accurate so you're only doing 7 min burns

 

[MD87]

On another thread someone posted about doing intracept with IV sedation only.

Anyone do that? What are your recommendations and advice?

It would make my life easier if I didn’t have to deal with anesthesia, but also don’t want to get in over my head.

I’ve done 9.
I would not feel comfortable using just IV sedation at this point. Even a seemingly simple 1 level case can be difficult, particularly at S1, if the patient’s anatomy/bone density create problems for you. Also, you’ll be asking the rep how to use the equipment/tools, which would likely make the patient anxious during your first cases. At some point, I could consider IV sedation only if it was 1 level, not S1 in a male (this has been the most difficult to successfully ablate), and a very normal patient after having another 5-10 procedures under my belt.

 

[Ronin1]

I did my first 5 with GA then a few with MAC. The last 5 have been IV sedation. No issues. It does take a bit longer than with general for procedure time. But overall much faster than in the OR. In the OR I can do 3 levels in 25 -30 minutes. With sedation that time only gets me two levels. It’s the way to go if you have that option for most patients.

 

[RoloTomassi]

not S1 in a male (this has been the most difficult to successfully ablate)

Fwiw almost every time I've used drill has been AA F, maybe 1 AA M. S1 and L5 only I think.

 

[MD87]

Fwiw almost every time I've used drill has been AA F, maybe 1 AA M. S1 and L5 only I think.

I had a patient where the J turned in on itself at S1 on 2 different approaches. I eventually aborted S1 and just did L5. Very hard bone.

 

[BobBarker]

I had to abort a s1 also. Lady who was using testosterone pellets.

 

[RoloTomassi]

I had a patient where the J turned in on itself at S1 on 2 different approaches. I eventually aborted S1 and just did L5. Very hard bone.

When I've experienced this put the trocar back in, bevel medialized, and drive it deep through the density, or use drill if that is too hard. In a female you can usually oblique it enough to take the trocar almost all the way to midline and minimize the J travel.

 

[GatorCHOMPions]

What's the oldest patient someone has done this procedure on? Age is just a number until...?

 

[Taus]

87

no age cutoff for me unless not cleared for anesthesia or comorbidities prohibit doing case in Asc.

 

[Ronin1]

92… no sweat. 25ug fentanyl iv and local
2 levels

 

[BobBarker]

We do kyphos on ancient people. Age not a concern