Experience with Intracept.
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per rep and data sheet they sent me…. ASC profits about 3k per case for Medicare. True or bs?
Don't do Medicare in ASC so I can't say definitively but that seems about right. But keep in mind it's a GA or MAC case, the staff needed, room turnover time, total case time, opportunity cost
I signed up for the training course in Boston in June…. Kind of excited to get started on this. The company takes care of the prior auth, rep quoting about 2/3 success rate with commercial carriers, can take up to three months though. Horizon however officially covers it.
Nice. Commercial is less than 2/3 in my experience.
It's a cool procedure. In my partner's experience (I've got my first two scheduled but haven't done any yet) it works really well. But it absolutely loses money if you're not tied into the ASC
Anyone have a template to share for your office notes to satisfy the insurance approval criteria? Ie 6 months axial lbp, failed conservative, diagnosis/mri with modic or equivalent, etc?
I extrapolate from vertebral augmentation
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Today, I am recommending the Intracept procedure for this patient. The patient meets the following criteria:
1-low back pain for greater than 6 months
2-low back pain that is unresponsive to conservative therapy for more than 6 months
3-the patient does have endplate changes including inflammation, edema, disruption.
This has been affecting the patient's ADLs including sleep, work, and performing leisure activities.
Furthermore, the patient's pain is located in the lower back and started [] years ago. The patient's pain score is currently rated at least an 8 out of 10. This is affecting the patient's ability to perform recreational activities as well as work. The patient has had numerous injections including [] in addition to medications including [] and physical therapy.
The patient has had an MRI is indicated above and in the patient's medical record.
The patient is having vertebrogenic chronic low back pain as well as these Modic changes at levels [].
I plan is to perform the Intracept procedure. Until we can get it approved, we will continue the patient on the current regimen as outlined in the medical record.
Popped my cherry on this- did my first case earlier this week. Definitely a learning curve, particularly for the feel of it, as I haven’t done vertebral augmentation, transpedicular access since fellowship in 14. After some initial troubleshooting, where the rep was very helpful, All went smoothly, took a little over an hour. Should get down to 30 to 40 minutes with the new seven minute burn time. So far this case appears to be a home run, chronic constant midline axial is gone pod 1. Very different from medial branch RF, more analogous to root canal. I know they won’t all be home runs like this, but will take it. Second case is next week.
Probably what I have enjoyed the most is the shift in conversation seeing these patients in the office, where previously we had no more decent options to offer once the usual conservative care fails…. Beyond conversation of acceptance, coping, learning to live with chronic pain etc., which sucks
I also just did my first. Patient had a ton of pain in PACU and had to stay overnight for a PCA. Saw for one week follow up and was doing great with near complete resolution of midline pain and just some post op soreness, overall pt extremely satisfied so far.
The immediate post procedure pain is variable, but it is the most intense part of recovery. Never had anyone that bad. Worse was hanging out for a few hours getting some IV meds and oral opioid for the road.
Definitely patient factors contributing to it. Had a lot of preprocedural anxiety and unrealistic immediate post-proc expectations. Made for a lot of headache in recovery room and on the floor, though.
Wow.
I don’t know if it made a difference or not, but I put marcaine from skin to bone with a 22g, as I would for stim, before putting In cannula
Yeah, did the same. 50/50 2% lidocaine and 0.50% bupivicaine.
I will say she had pretty impressive bone density and we hammered the crap out of the pedicles to get in. Definitely bringing a bigger mallet next time for my own sake!
I’ve only heard a rep talking about how amazing the procedure is, and kept trying to see where it fails or what he wasn’t telling me. But, it’s sounding like aside from the post-op recovery, real world results have been lining up with what they’re publishing?
Yes, my results have been in line.
I will say though that since Modic changes are not 100% correlated with LBP and there's no diagnostic block, you are going to have patients who look like perfect candidates, have perfect placement, and get no relief. Always a big let down, similar to the perfect FBSS/CRPS pt who gets no relief from an SCS trial. But even taking that into account, success rates are still high enough not to deter me one bit. Just make sure you set those expectations.
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IV steroids intra-op? The course directors at mine strongly encouraged. I gave 125mg solumedrol
Bone density on mine was really tough too… had 2lb mallet. Will request 5lb available next case. I’ve heard some people have used a drill… not sure I’d be comfortable with that
I don't do steroids. First few cases I did an ILESI, then stopped and saw no difference. Drill has come in handy a couple times. Just a hand drill. If you hit a hard spot just put in, corkscrew a few mm to get past it, and put diamond stylet back in. A lot less elbow grease and trauma than slamming away.
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Guys, forget about what they are telling you going through the pedicle. Just go extrapedicular every time. The younger pedicles are too hard. I am placing each trochar in a couple minutes extrapedicular. The angles work well also for electrode placement.
I rarely find it too hard. If you're mid pedicle it is actually pretty soft. Not compression fx soft but definitely not much effort, usually.
But, I am very interested in which extrapedicular approach you are using for lumbar. Can you describe in more detail and/or pics?
We always did an ILESI during fellowship. Never did IV steroids. Haven’t done either in practice. No issues so far but small sample size. No problems with hard bone in pedicles yet but have run into this issue within the S1 vertebral body which can deflect the curved nitinol probe/stylet and get you off target.
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I got the Relievant Insider in my email frequently. I have not been offered training, but as I am a public naysayer.....
A couple nice pain docs around me doing this: Tate, Bishop, Mangrum, Schaufele. I can refer them out.
Find a rep on LinkedIn
It is the same approach that is my default for kyphos. Basically high and outside the pedicle.
This video goes over both that approach and low and outside which can be good for getting around hardware.
This video goes over both that approach and low and outside which can be good for getting around hardware.
Have you ever done that modified inferior endplate approach? I don't see how it's not risking nerve root injury
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Yes, I have. On a near plana fx. No issues.
Great video - thanks for sharing. I about dropped my phone when I saw his first image of the extrapedicular approach! The trajectory seemed to violate everything I learned in fellowship. Parapedicular seems like a really good option to think about though.
Case 2- >50% relief on pod 2…. Hasn’t felt this good in years…. Definitely much more comfortable with the technique now and it was kind of fun. Open to doing more of this.
Probably would. Just burn it 85 deg for 15 min and it should mimic the Intracept protocol.
These authors did it with the STAR Tumor Ablation system under local anesthetic. I've done w/ IV conscious.
Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain - PubMed
Percutaneous CT-guided intra-osseous BVA seems to be a safe, fast, and powerful technique for pain relief in patients with vertebrogenic chronic LBP, when the selection of patients is based on a multidisciplinary approach including both conventional Diagnostic Radiology and Nuclear Medicine imaging.
pubmed.ncbi.nlm.nih.gov
Probably would. Just burn it 85 deg for 15 min and it should mimic the Intracept protocol.
These authors did it with the STAR Tumor Ablation system under local anesthetic. I've done w/ IV conscious.
Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain - PubMed
Percutaneous CT-guided intra-osseous BVA seems to be a safe, fast, and powerful technique for pain relief in patients with vertebrogenic chronic LBP, when the selection of patients is based on a multidisciplinary approach including both conventional Diagnostic Radiology and Nuclear Medicine imaging.
Very interesting, however I would think a challenge to get the Jamshidi through younger hard bone with mallet bilaterally under local. Then there is also the issue of local anesthetic vascular uptake, i.e. not allowing for a good local at the burn site/electrode tip inside the vertebral body. Other concern would be getting medial enough while still being posterior in vertebral body without their J stylet. Perhaps with a very far lateral to medial approach, ie extrapedicular. Also, as above, that was Star tumor ablation system, not standard RF with 10 mm bent tip as with medial branches
He went to jail for 36 months.
Damn...Brutal takedown.
Mitch, This is ur GA/Athens rep, cheers.
+1 (678) 427-4743
Michael rodenheiser
- addendum: he just replied, no one in Athens doing it, he’d be happy to get it rolling with you
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Thanks my friend.
What has been your experience getting auth with commercial insurances? Specific carriers approving more than others, timeframe, etc? My cases have been Medicare and Highmark (approves easily if meet criteria). Multiple others going through appeals process in portal over several months.
I don’t think anything other than Medicare or the State employee insurance program will get done here.
Bummer. I’ve heard 2/3 commercial cases eventually approved from reps, takes a few months, but I’m skeptical and will believe it when I see it…. I also have not found anyone who can tell me what the pro fee at asc has been on a commercial case
My rep said that he hadn’t had a bcbs case approved since the new code came out January 1st.
A lot less than 2/3. Last year, off the top of my head 20%. Only 1 this year. Many months usually, 2-3 level appeals. A few weeks on the fast end, always has been with patients who get very involved with pressuring their insurance. Never Cigna. Last year pro fee all over the map. This year, the one, about same as Medicare
Thank you for the information. That is certainly disappointing.
I am pretty excited about this procedure… Two for two so far. My second case is about two weeks out, over 85% relief, best has felt in years. First case three weeks out over 95% relief.
Several more pending, but all Medicare. Hopefully the situation will improve with commercial coverage, or maybe I will get lucky and payers in my area will be a little easier to approve. I will definitely get patients on the horn with their insurance companies.
D
deleted131481
I just watched this, thanks for posting. Sounds the high and outside approach is what Beall refers to in the video as "parapedicular". Here is the attached article he references if anyone is interested.
A few questions for you:
1) So did you switch to this approach primarily for ease/time?
2) Any particular situations you go back to transpedicular?
3) And for thoracic - you're basically hugging medial rib and passing right through the costovertebral and costotransverse joints as I understand it. I attached an image - is the orange marker (mine) correct target for thoracic oblique?
I think I'll try this on my next lumbar.
Attachments
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