Experience with Intracept.

[RoloTomassi]

Which facets?

b/l L2-4 facet joints

ESI for axial LBP?

Axial pain is predominant but some upper buttock and thigh pain, thought it was worth a try

Would have done L2-3 only, if I did these.

Didn't want to neglect inferior endplate of L1

Or Belbuca 150 bid and good luck.

She doesn't want meds. Thanks

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[fathead88]

Based on the info I think BVN ablation is reasonable. My understanding is that it is only approved for L3 and below? Do you plan to bill the L1 and L2 levels?

 

[lobelsteve]

b/l L2-4 facet joints

Axial pain is predominant but some upper buttock and thigh pain, thought it was worth a try

Didn't want to neglect inferior endplate of L1

She doesn't want meds. Thanks

Tough case with a no win situation. I think you did it perfectly.

 

[RoloTomassi]

Based on the info I think BVN ablation is reasonable. My understanding is that it is only approved for L3 and below? Do you plan to bill the L1 and L2 levels?

Got approval for L2-3, doing L1 as freebie

 

[deleted875186]

If they were to extend that fusion- it would be 3 additional vertebral levels fused. If successful, she maybe would have 1-2 good years before adjacent level degeneration kicks and this will be a miserable back once again.

Several surgeons in my area do L2-S1 fusion and lami for many patients they see ….. “there’s severe canal stenosis at L4-5, but then there’s a protrusion and mild stenosis up at L2-3 and 3-4, might as well fuse those”.

 

[rexed]

It’s getting a CPT code next year.

I've been told by the rep CPT code is coming this October.

 

[bedrock]

Due to reimbursement issues I now do most cases in outside ASC, make very little on the pro fee side. Make more per hour doing bread and butter.

How low is the reimbursement? Is it clinic low? or just lower than doing ESI/MBB?

I'm interested in helping patients with whatever is appropriate, however if it doesn't reimburse me appropriately I don't plan to offer it myself.

I may refer out some of these patients in the future to a HOPD based physician who does them, though I'm curious just how low is the ASC pro fee?

Do the RVUs make sense for an HOPD employed physician?

 

[RoloTomassi]

How low is the reimbursement? Is it clinic low? or just lower than doing ESI/MBB?

I'm interested in helping patients with whatever is appropriate, however if it doesn't reimburse me appropriately I don't plan to offer it myself.

I may refer out some of these patients in the future to a HOPD based physician who does them, though I'm curious just how low is the ASC pro fee?

Do the RVUs make sense for an HOPD employed physician?

Medicare, pro fee closer to E&M, ASC fee is profitable if efficient, HOPD is nice margin. Commercial is all over the place, can be a loss, can be bank. For Medicare, I do them when I would otherwise be in bed so it's not nothing, and it's a fun procedure.

 

[bedrock]

Medicare, pro fee closer to E&M, ASC fee is profitable if efficient, HOPD is nice margin. Commercial is all over the place, can be a loss, can be bank. For Medicare, I do them when I would otherwise be in bed so it's not nothing, and it's a fun procedure.

Thanks

 

[ziggyziggy]

Did my first case today.

It reminds me of when I did my first nucleoplasty. I was so excited. What a great name - was it Dekompressor?

I'm much less enthusiastic this time, however.

Did this case today. Severe axial LBP. Failed RFA. Failed TFESI and ILESI. Stenosis severe but not as bad on axials. If Intracept not an option, and fails SCS, you wouldn't even consider fusion extension? Anecdotal but I'll let you know how she does 2 weeks after L1/2/3 BVNA

updates?

 

[NJPAIN]

Did my first case today.

It reminds me of when I did my first nucleoplasty. I was so excited. What a great name - was it Dekompressor?

I'm much less enthusiastic this time, however.

I can’t imagine anything being more disappointing than the Dekompressor.

 

[drusso]

We're seeing an epidemic of Modic-related back pain now. It seems to be everywhere.

 

[clubdeac]

Now at the end of every MRI report that has modic changes our radiologists make special note of the changes and state they could be amenable to Intracept. They also add their scheduling number to get the patient in for an urgent consult

 

[Agast]

Now at the end of every MRI report that has modic changes our radiologists make special note of the changes and state they could be amenable to Intracept. They also add their scheduling number to get the patient in for an urgent consult

Man, talk about a solution looking for a problem to fix

 

[drusso]

Now at the end of every MRI report that has modic changes our radiologists make special note of the changes and state they could be amenable to Intracept. They also add their scheduling number to get the patient in for an urgent consult

We're seeing epidemic levels of Modic-related back pain.

 

[RoloTomassi]

updates?

Minimal improvement on this one. Bummer.

 

[ziggyziggy]

Minimal improvement on this one. Bummer.

Thanks for the update. Its difficult too find honest person and more so, a truth telling pain physician

 

[lobelsteve]

Thanks for the update. Its difficult too find honest person and more so, a truth telling pain physician

Rolo is legit.

 

[lobelsteve]

Methodological concerns of “Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain” - Neuroradiology

link.springer.com

Anyone got access to the letter to the editor?

 

[fathead88]

We’ve had a few patients in our practice do very well after BVN ablation in the past 3 or 4 months. Like 2-3/10 pain down from years of 8-9/10 and are saying “I havent had this much pain relief in years.” I think there’s definitely a patient population that benefits from my anecdotal experience.

 

[drrosenrosen]

We’ve had a few patients in our practice do very well after BVN ablation in the past 3 or 4 months. Like 2-3/10 pain down from years of 8-9/10 and are saying “I havent had this much pain relief in years.” I think there’s definitely a patient population that benefits from my anecdotal experience.

My partner has been doing these for about six months, and has been very impressed with results. As you describe, significant pain reduction, and "haven't had this much pain relief in years". I've identified a few good patients myself and am getting lined up to do the training. We only do in hospital, though we do 95% of our other procedures in office.

 

[deleted131481]

Methodological concerns of “Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain” - Neuroradiology

link.springer.com

Anyone got access to the letter to the editor?

 

[drusso]

What a tone-deaf letter to write during an epidemic of Modic-related back pain....Shame.

 

[epidural man]

I question the conclusion.

“In fact, low-quality research can mislead clinicians, harm patients, and drain resources away from high-quality, clini- cally useful endeavors.”

Are there high-quality clinically useful endeavors in pain medicine?

 

[Baron Samedi]

Did my training recently -- was astonished at the reimbursement rates. Is there any way this makes sense at all for anyone to perform these on the regular or is it all charity?

 

[drusso]

Did my training recently -- was astonished at the reimbursement rates. Is there any way this makes sense at all for anyone to perform these on the regular or is it all charity?

Are you getting a piece of the facility fee?

 

[Baron Samedi]

Are you getting a piece of the facility fee?

I'm govt employee so it doesn't really apply to me but was curious how it works for others who do this procedure.

 

[Taus]

I’ve recently heard Medicare pro fee in ASC is about $450 and facility reimbursement in asc is now viable, ie not just restricted to hopd. Can anyone confirm?

Also, any commercial insurance covering now that the new codes exist?

Thanks

 

[MitchLevi]

I’ve recently heard Medicare pro fee in ASC is about $450 and facility reimbursement in asc is now viable, ie not just restricted to hopd. Can anyone confirm?

Also, any commercial insurance covering now that the new codes exist?

Thanks

How long does this procedure take to do? I've heard upwards of 45-60 min.

Is that true? How many ESI/RFA/trials can I do in that amount of time? In one hour I can see 5 clinic pts (new and follow up) and that leads to 3-4 procedures getting scheduled.

Our outcomes THAT good? I'd love to train up on it but damn man...

 

[Taus]

How long does this procedure take to do? I've heard upwards of 45-60 min.

Is that true? How many ESI/RFA/trials can I do in that amount of time? In one hour I can see 5 clinic pts (new and follow up) and that leads to 3-4 procedures getting scheduled.

Our outcomes THAT good? I'd love to train up on it but damn man...

I see 3 per hour in office. Three basic procedures per hour in ASC (4/hour in office fluoro)….. So if this takes 45 minutes to an hour and we are talking Medicare rates in office and ASC pro fees… Sounds approx net neutral, for me at least. If that is the case I would not be opposed to do a few per month. I don’t think I see more than that per month who would be a candidate for this in terms of imaging as well as not responding to a more conservative care (fortunately).

When the outcomes for any procedure in this population (esi, regen, fusion) Are really about 50% get decent relief….. I’m not fully opposed to doing this.

 

[Baron Samedi]

The instructor at the course said he does them all under GA in OR and books for 1.5hr for 2-3 level treatment.

They also mentioned that insurance is still a major hurdle and to expect multiple denials, P2P, and addendum requests for radiologists to specifically mention modic changes for approval. Lotttt of leg work it looks like.

 

[lobelsteve]

Still not impressed with the literature. As bad or worse than most of our interventional care.
Procedure looks like fun, just not sure I'd be helping anyone above placebo.

 

[Baron Samedi]

Still not impressed with the literature. As bad or worse than most of our interventional care.
Procedure looks like fun, just not sure I'd be helping anyone above placebo.

They claim that the BVN never regenerates because its unmyelinated leading to permanent relief.

Mechanistically that doesn't make sense to me since unmyelinated nerve fibers regenerate all the time (C fibers after RFA).

 

[lobelsteve]

They claim that the BVN never regenerates because its unmyelinated leading to permanent relief.

Mechanistically that doesn't make sense to me since unmyelinated nerve fibers regenerate all the time (C fibers after RFA).

Sham group at 3 mo had clinically significant ODI similar to treatment group.

 

[bedrock]

The instructor at the course said he does them all under GA in OR and books for 1.5hr for 2-3 level treatment.

They also mentioned that insurance is still a major hurdle and to expect multiple denials, P2P, and addendum requests for radiologists to specifically mention modic changes for approval. Lotttt of leg work it looks like.

I see 3 per hour in office. Three basic procedures per hour in ASC (4/hour in office fluoro)….. So if this takes 45 minutes to an hour and we are talking Medicare rates in office and ASC pro fees… Sounds approx net neutral, for me at least. If that is the case I would not be opposed to do a few per month. I don’t think I see more than that per month who would be a candidate for this in terms of imaging as well as not responding to a more conservative care (fortunately).

When the outcomes for any procedure in this population (esi, regen, fusion) Are really about 50% get decent relief….. I’m not fully opposed to doing this.

I applaud you both for considering it. Personally, I'm at 105% capacity and don't see a personal reason for me to do this, particularly the extra leg work of appeals, asking radiology to change reads etc. I will do that for a stim trial that makes $$$$ for our ASC, but not something that pays less than I make in clinic.

I will still refer out the odd patient, however, as I want patient to get better, but not by me losing money and time. Haven't heard back from any of them yet. If you could just order one up like an RFA, then I would be more likely to accept the poor pay, but not an insurance hassle AND poor pay.

 

[RoloTomassi]

The instructor at the course said he does them all under GA in OR and books for 1.5hr for 2-3 level treatment.

They also mentioned that insurance is still a major hurdle and to expect multiple denials, P2P, and addendum requests for radiologists to specifically mention modic changes for approval. Lotttt of leg work it looks like.

All correct.

Basically you put the first trocar in (if all goes well, 10-15 min), burn for 15 min. While burning, you put the next one in. Ideally you always finish placing before the previous level is done burning, so the 15 min burns are rate limiting.

2 level: 15 min place 1, 15 burn 1, 15 burn 2 = 45 min, and every additional is 15 per.

They usually go this way but a number of things can make a placement go sideways and > 15 min. If multilevel and multi tough placements, can get long.

Given potential to go long, I prefer GA on multilevel, fat, old, comorbities. Plus don't have to waste time numbing, adjusting MAC if patient pt squirmy.

On a 2 level, thin healthy pt, MAC is fine. Some have done CS but I don't have experience. Want to try but if they start screaming during the 15 min burn, it'd be a nightmare since you can't grit through like a 90 sec RFA.

Medicare pro fee sucks. Commercial is hit or miss. I make more doing regular injections and E&M from opportunity cost perspective, so I do these on my off-day. Also can be seen as a loss leader. Gotten tons of word of mouth referrals from happy patients, some willing to self-pay. One self payer makes up for a lot.

ASC margins are tight but still profitable if you run an efficient ASC, unless you do multilevel or run long and eat into OR time.

 

[Taus]

All correct.

Basically you put the first trocar in (if all goes well, 10-15 min), burn for 15 min. While burning, you put the next one in. Ideally you always finish placing before the previous level is done burning, so the 15 min burns are rate limiting.

2 level: 15 min place 1, 15 burn 1, 15 burn 2 = 45 min, and every additional is 15 per.

They usually go this way but a number of things can make a placement go sideways and > 15 min. If multilevel and multi tough placements, can get long.

Given potential to go long, I prefer GA on multilevel, fat, old, comorbities. Plus don't have to waste time numbing, adjusting MAC if patient pt squirmy.

On a 2 level, thin healthy pt, MAC is fine. Some have done CS but I don't have experience. Want to try but if they start screaming during the 15 min burn, it'd be a nightmare since you can't grit through like a 90 sec RFA.

Medicare pro fee sucks. Commercial is hit or miss. I make more doing regular injections and E&M from opportunity cost perspective, so I do these on my off-day. Also can be seen as a loss leader. Gotten tons of word of mouth referrals from happy patients, some willing to self-pay. One self payer makes up for a lot.

ASC margins are tight but still profitable if you run an efficient ASC, unless you do multilevel or run long and eat into OR time.

Thanks for the insight. I’m on the fence….

 

[MitchLevi]

Thanks Rolo.

I see 25-30 pts per day, not ultra high vol, but I saw a total of 5700 pts last yr and I'm not sure how many of them are right for this procedure.

How exactly is that decision made? What criteria make you a candidate?

Axial pain with Modic 1 change?

I'm assuming this is a procedure of exclusion right?

 

[lobelsteve]

Thanks Rolo.

I see 25-30 pts per day, not ultra high vol, but I saw a total of 5700 pts last yr and I'm not sure how many of them are right for this procedure.

How exactly is that decision made? What criteria make you a candidate?

Axial pain with Modic 1 change?

I'm assuming this is a procedure of exclusion right?

Modic changes.
Failed less aggressive interventions.
Failed PT.
No psych comorbidities.
Great insurance so you are not wasting your time.

 

[MitchLevi]

Any Modic?

 

[Taus]

Any Modic?

1 or 2


I have been on the fence about offering intradiscal regen…. I get the itch to do it every few months when I have what I believe is an ideal candidate clinically who also fully gets that its about 50% get 50% relief based on the best available literature. Never pulled the trigger. Thus far I’ve sent this handful of patients per year to a local colleague at another practice. Perhaps I’d have more “perfect” candidates if I was the one getting paid cash to do it….

I think I feel more comfortable with offering bvn rf

 

[RoloTomassi]

Thanks Rolo.

I see 25-30 pts per day, not ultra high vol, but I saw a total of 5700 pts last yr and I'm not sure how many of them are right for this procedure.

How exactly is that decision made? What criteria make you a candidate?

Axial pain with Modic 1 change?

I'm assuming this is a procedure of exclusion right?

Axial pain > 6 mo with Modic 1 or 2 on MRI, not responsive to conservative tx is the official criteria for indication/approval.

Anecdotally better results if you can really isolate: failed MBB/RFA/SIJ, not much disc left to be a purely discogenic/annular fissure type pain, single level, younger. Those are home run candidates.

 

[lobelsteve]

Axial pain > 6 mo with Modic 1 or 2 on MRI, not responsive to conservative tx is the official criteria for indication/approval.

Anecdotally better results if you can really isolate: failed MBB/RFA/SIJ, not much disc left to be a purely discogenic/annular fissure type pain, single level, younger. Those are home run candidates.

Home run = 50% of pts that reach 50% relief.

 

[Taus]

Home run = 50% of pts that reach 50% relief.

Yes. The same for any procedure for axial “discovertebral” pain.

 

[RoloTomassi]

Oh and symptoms consistent with anterior column pain--worse with BLT, sitting, less with standing, walking, pristine facets. Not always sensitive/specific. Really no different from discogenic. Given the lack of options for discogenic, I'll do it with the slightest bit of Modic. There was a study that showed MRI Modic changes aren't even sensitive for picking up endplate nerve proliferation, which is higher density than in actual disc. So I don't always do MBB is what I'm getting at.

 

[RoloTomassi]

Home run = 50% of pts that reach 50% relief.

70% change of >50%, 50% chance >75%, 33% pain free.

 

[RoloTomassi]

1 or 2


I have been on the fence about offering intradiscal regen…. I get the itch to do it every few months when I have what I believe is an ideal candidate clinically who also fully gets that its about 50% get 50% relief based on the best available literature. Never pulled the trigger. Thus far I’ve sent this handful of patients per year to a local colleague at another practice. Perhaps I’d have more “perfect” candidates if I was the one getting paid cash to do it….

I think I feel more comfortable with offering bvn rf

I used to do some intradiscal BMAC, but that's down to 1-2 / year. Will always do Intracept first if any Modic, and have been surprised. It's so much better tolerated and lower risk that there's no reason to do intradiscal first. Probably have lost money from this algorithm too.

 

[Dr. Ice]

Have had good success with intradiscal prp..mind you, as there maybe a component of facet pain, I usually use a 60 pure and inject 3 into the disc and the remainder (usually another 3) into the facet joints. I’ve been surprised by the positive response in many.

Taus, if you want, send your patients to me and tell them that I used to work there 😉

Where are you sending them now? Mainline spine?

 

[drrosenrosen]

I just went to the course this weekend (Baron Samedi and I may have been at the same course?). More impressive for me than any literature the company can quote is my partner's experience - he probably did 10-15 last year, and all of his patients but one have had significant relief 75%+, with the longest follow up so far being a year. My schedule is not full since I just started last summer with this group. So I'm going to offer it because I don't always have an hour's worth of SCS trials and RFAs that I could be doing instead. But I agree the reimbursement is a real bummer.

 

[Baron Samedi]

I just went to the course this weekend (Baron Samedi and I may have been at the same course?). More impressive for me than any literature the company can quote is my partner's experience - he probably did 10-15 last year, and all of his patients but one have had significant relief 75%+, with the longest follow up so far being a year. My schedule is not full since I just started last summer with this group. So I'm going to offer it because I don't always have an hour's worth of SCS trials and RFAs that I could be doing instead. But I agree the reimbursement is a real bummer.

Mine was in TX. I was pretty vocal about the reimbursement issues, lol. Right now I'm 100% salary and don't run into RVU issues so I will likely offer it, but I do wonder about their company future. Wonder if they'll seek an exit with Stryker or someone similar.