Experience with Intracept.

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BobBarker said:
98% of our PMR colleagues think GA=ETT so I was writing for that audience. Anesthesia is a gradient. Intracept on osteoporotic bone can probably be done with sedation. Difficult or barbaric to drive a spike through non osteoporotic pedicle without GA. I would say the majority of my prone, TIVA cases are clearly GA without an airway.

No offense PMR friends. We don’t understand EMGs very well.
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What’s an EMG?
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Level of sedation is variable, dependent on patient pain tolerance, comorbidities, bone density, number of levels, 7 v 15 min burns, how fast you are.

Most will do better with deep sedation/ unconscious/general.

But if circumstances call for moderate/conscious, it can be done without too much discomfort. The trials at Emory were done this way. Numb the periosteum, go down the center of pedicle where it's softer, use hand drill rather than pounding at densities/cortex, make sure you get 7 min burns, slow movement of stylets. I have experience doing kyphos and BMA under local which I think helps.

FWIW I recently did IV conscious on a 50 yo black male I previously did b/l C3-5 cervical RFA 18 ga Sidekick on, same amount of meds (2-3 mg Versed, 150 mcg fent), and he said the RFA was worse.
 
54 yo active male s/p L2-4 decompression circa 2018. I've ablated and ESI him without benefit. Pic quality isn't great, but he's about to see a surgeon and doesn't want to do it.

Candidate?

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lobelsteve said:
Only at L2-3. And thee is nothing surgical on that MRI.
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Agree.

As he wants to try it now, and I'm still not trained on it I may have to send him to another SDN user nearby to have it done.
 
I think for sure try L2-3. Then SCS. I don’t see how a stand alone L2-3 fusion could stay stand alone for very long with the decompression already being done to L4.
 
SC Tian said:
Anyone was able to negotiate down the price of the intracept kit, it is reported $6400? The profit margin for Medicare patients is so low here in ASC?
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Have you looked at the Merit Medical STAR system? Same idea but meant for tumor ablation. Been using them with good results. They're a little harder to do as compared to Intracept as there is no nitinol sheath to put the ablation system through so you have to find the track, and it's not a fixed curve so you gotta think through the approach/curvature.

The cost is cheaper tho and it has shorter burn times with reliable lesion sizes.
 
MitchLevi said:
54 yo active male s/p L2-4 decompression circa 2018. I've ablated and ESI him without benefit. Pic quality isn't great, but he's about to see a surgeon and doesn't want to do it.

Candidate?

View attachment 374197View attachment 374198
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Flex/Ex standing xray?

I would probably offer intercept, but with tempered expectations here. That said, no bridges are burned. If fails, I can still go for surgical referral, particularly if there is motion at the L2-3 segment on the standing x-rays.
 
Taus said:
Flex/Ex standing xray?

I would probably offer intercept, but with tempered expectations here. That said, no bridges are burned. If fails, I can still go for surgical referral, particularly if there is motion at the L2-3 segment on the standing x-rays.
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Any issues getting authed for L2-L3?
I thought the intracept procedure was fad approved just for L3-L4 through L5-S1?

Happen to know if I’m misunderstanding this.
 
bedrock said:
Any issues getting authed for L2-L3?
I thought the intracept procedure was fad approved just for L3-L4 through L5-S1?

Happen to know if I’m misunderstanding this.
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Might run into problems. Since L3 is involved it's considered the first level even though only half technically, and L2 is freebie. So still should pay the same. But 54yo so low likelihood of approval regardless
 
RoloTomassi said:
Might run into problems. Since L3 is involved it's considered the first level even though only half technically, and L2 is freebie. So still should pay the same. But 54yo so low likelihood of approval regardless
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Thanks.

Which insurances (other than Medicare) are paying for intracept most consistently?

Are there some insurances that are complete hopeless with intracept? As in you shouldn’t even mention it to those patients because it is denied every time?
 
bedrock said:
Thanks.

Which insurances (other than Medicare) are paying for intracept most consistently?

Are there some insurances that are complete hopeless with intracept? As in you shouldn’t even mention it to those patients because it is denied every time?
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Cigna just released guidelines for approval. Have yet to see one but they went into effect less than a month ago. Only 1 level, need to fail CBT, some other hoops. None are hopeless but in the 10-30% success rate range.
 
Fail CBT? I have no one I can send to for that.
 
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RoloTomassi said:
Cigna just released guidelines for approval. Have yet to see one but they went into effect less than a month ago. Only 1 level, need to fail CBT, some other hoops. None are hopeless but in the 10-30% success rate range.
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Agreed, except I would say Aetna is hopeless and that I have seen more approvals this year than last year. I quote 3 to 6 months to patients.
 
Taus said:
Available via telehealth. Several companies out there, have used a few for my stim psych clearances. Much better insurance coverage and faster turnaround than local psychologists
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BS

I use tele pain psych for stim and there's no chance that's effective for CBT. No way. Tele-anything is impersonal. Pain psych needs to be deeply personal and you must connect with that pain psychologist on a level I just can't imagine is possible over tele.
 
RoloTomassi said:
Cigna just released guidelines for approval. Have yet to see one but they went into effect less than a month ago. Only 1 level, need to fail CBT, some other hoops. None are hopeless but in the 10-30% success rate range.
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Nice. Cigna was one of the ones I was most worried about.

So for the group, are there any other major insurance companies that just will never cover it such as UHC?
Taus said:
Agreed, except I would say Aetna is hopeless and that I have seen more approvals this year than last year. I quote 3 to 6 months to patients.
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Thank you. I won’t bother sending those patients. Let he group know if that changes.
 
MitchLevi said:
BS

I use tele pain psych for stim and there's no chance that's effective for CBT. No way. Tele-anything is impersonal. Pain psych needs to be deeply personal and you must connect with that pain psychologist on a level I just can't imagine is possible over tele.
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True. Though CBT is not very effective much of the time anyway.

I’d definitely prescribe intracept over CBT (standard of CBT for last 50 years) , if I see a patient with mod-severe axial LBP, who failed conservative care , and whose facets have been ruled out if they have even modest modic changes.

For me that’s still only two patients referred in an average month.
 
MitchLevi said:
BS

I use tele pain psych for stim and there's no chance that's effective for CBT. No way. Tele-anything is impersonal. Pain psych needs to be deeply personal and you must connect with that pain psychologist on a level I just can't imagine is possible over tele.
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Do you think I am using it because it is effective??!

Cigna requires 3 sessions of CBT to approve intracept…. Check that box

Scs trial in normal patient…. Sure

Someone who needs active pain psych treatment… different story
 
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Taus said:
Do you think I am using it because it is effective??!

Cigna requires 3 sessions of CBT to approve intracept…. Check that box

Scs trial in normal patient…. Sure

Someone who needs active pain psych treatment… different story
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3 sessions WTF...What does that even mean? How arbitrary is that?

I know you're checking the box. It's just infuriating.
 
I've seen MAC listed as anesthetic technique when it is obviously GA. If the patient is sedated to the point where they cannot protect their airway it is GA. Pour water down their throat and they would drown.
 
Taus said:
Cigna requires 3 sessions of CBT and only covers 1 level (2 vert bodies) for intracept. Complete bs.
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Wow. It is crazy that Cigna would decide to cover this important treatment only to then fall at the finish line and only cover one level.

There many patients with significant two level DDD with two level modic changes.
 
Taus said:
Cigna requires 3 sessions of CBT and only covers 1 level (2 vert bodies) for intracept. Complete bs.
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Wow. It is crazy that Cigna would decide to cover this important treatment only to then fall at the finish line and only cover one level.

There many patients with significant two level DDD with two level modic changes.
 
Yet vastly more expensive multilevel fusions never have psych requirement
 
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My experience with BCBS has been dismal. 3 patients in the past year, all denied, appeal denied, external review denied. It's a promising treatment - although I have had my first couple of patients who didn't do well, now about 5/7 success - but between the approval hassles, the meager reimbursement, and only being able to do it in a hospital, it's going to die.
 
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drrosenrosen said:
My experience with BCBS has been dismal. 3 patients in the past year, all denied, appeal denied, external review denied. It's a promising treatment - although I have had my first couple of patients who didn't do well, now about 5/7 success - but between the approval hassles, the meager reimbursement, and only being able to do it in a hospital, it's going to die.
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I feel like right now I am providing adequate pain care to my patient's, and the vast majority do better once they're established with me and we've taken a few steps down the treatment algorithm.

I don't do Intracept (yet), but I fail to see where any significant portion of my patient population is lacking by my not offering it.

High-quality RFA and ESI seem to work pretty good in Athens and Loganville, GA.

The above patient that I posted - It's L2-3 and he's got United HC insurance. Is this procedure even an option for him?

It seems anatomically it is a good idea to try it, but am I expected to put forth all of this effort of getting trained and going through all the insurance stuff and then given the time requirement in the procedure suite relative to the reimbursement...Is it even worth it?

Reading this site, yall appear to spend an exorbitant amount of time with insurance companies. It seems like a hassle TBH.

Not sure I really want to deal with this BS...
 
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MitchLevi said:
I feel like right now I am providing adequate pain care to my patient's, and the vast majority do better once they're established with me and we've taken a few steps down the treatment algorithm.

I don't do Intracept (yet), but I fail to see where any significant portion of my patient population is lacking by my not offering it.

High-quality RFA and ESI seem to work pretty good in Athens and Loganville, GA.

The above patient that I posted - It's L2-3 and he's got United HC insurance. Is this procedure even an option for him?

It seems anatomically it is a good idea to try it, but am I expected to put forth all of this effort of getting trained and going through all the insurance stuff and then given the time requirement in the procedure suite relative to the reimbursement...Is it even worth it?

Reading this site, yall appear to spend an exorbitant amount of time with insurance companies. It seems like a hassle TBH.

Not sure I really want to deal with this BS...
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The company does most the work. You do have to have a designated point person to input the patient into the system and that requires a bit of work on their end
 
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MitchLevi said:
I feel like right now I am providing adequate pain care to my patient's, and the vast majority do better once they're established with me and we've taken a few steps down the treatment algorithm.

I don't do Intracept (yet), but I fail to see where any significant portion of my patient population is lacking by my not offering it.

High-quality RFA and ESI seem to work pretty good in Athens and Loganville, GA.

The above patient that I posted - It's L2-3 and he's got United HC insurance. Is this procedure even an option for him?

It seems anatomically it is a good idea to try it, but am I expected to put forth all of this effort of getting trained and going through all the insurance stuff and then given the time requirement in the procedure suite relative to the reimbursement...Is it even worth it?

Reading this site, yall appear to spend an exorbitant amount of time with insurance companies. It seems like a hassle TBH.

Not sure I really want to deal with this BS...
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i think that we will have the typical experience with Intracept that we have had with all of these other pain therapies.

first, a huge rush to do the procedures. its a game changer. pain management will be forever changed.


initially it may pay well. reps are all over the place. ASPN conferences with multiple meetings and multiple pointed toes talking about how it is the great thing, will rewrite what we do.

then, the clinical experience. some will have great response. most will be, meh.

some docs will then start abusing and doing injections on marginal cases and even cases where it is not indicated, further diluting benefit.

then will come the struggles of getting it approved, as more and more docs do the procedure.

ultimately, it will stabilize, with overall some people getting benefit, most not, and a few doctors continue to advocate, and most move on to the next great thing.


lets see, in the past 10 years this pattern has happened with HF10. DRG. SI fusion. Vertiflex. Minuteman. MILD. periph stim.

Intracept is next...
 
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Intracept does not pay enough for the hassle to be abused. I think the current state of MILD is the same.
 
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I’ve gotten an approval from UHC. But they don’t allow itemization (device carvout) for Intracept so it’s not financially viable.

It’s profitable in the ASC with certain payers, not all. Dependent on contracts for each ASC. One the ASCs I use has been able to host while the other hasn’t in certain cases.
 
Intracept is challenging to do for UHN patients in the setting of ASC, the kit is considered disposable in our state, rather than an implant that can be reimbursed separately. The kit was charged an extra state tax that is added to the cost in ASC.
 
drrosenrosen said:
My experience with BCBS has been dismal. 3 patients in the past year, all denied, appeal denied, external review denied. It's a promising treatment - although I have had my first couple of patients who didn't do well, now about 5/7 success - but between the approval hassles, the meager reimbursement, and only being able to do it in a hospital, it's going to die.
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I have learned more about insurance approval and appeals processes over the last year and a half doing intracept than I cared to ever know. It’s really not too much work on my end. Dictate the note with a template to cover the indications for auth. Relievant handles the rest once my assistant uploads the information to the portal. Tell patients takes 3 to 6 months and may still not get approved. Getting more approvals this year than last. BCBS has been interesting. I had no idea there were so many subsets of it and regional differences. Some have it in their policy and easily approved (Highmark). Some get a fair amount of internal appeal approvals. Others get external independent appeal approvals more often than not. Some BCBS versions are near zero chance. Just about all Medicare advantage plans will ultimately get an authorization via administrative law judge hearing. Relievant handles that whole process. Is what it is for the time being. Should get better year-by-year, but clinically has definitely changed my practice for the better.
 
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SC Tian said:
Intracept is challenging to do for UHN patients in the setting of ASC, the kit is considered disposable in our state, rather than an implant that can be reimbursed separately. The kit was charged an extra state tax that is added to the cost in ASC.
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Taus said:
Agreed, except I would say Aetna is hopeless and that I have seen more approvals this year than last year. I quote 3 to 6 months to patients.
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Tboned said:
I’ve gotten an approval from UHC. But they don’t allow itemization (device carvout) for Intracept so it’s not financially viable.

It’s profitable in the ASC with certain payers, not all. Dependent on contracts for each ASC. One the ASCs I use has been able to host while the other hasn’t in certain cases.
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Thank you all.

Going forward I will refer intracept cases to the only guy in the state doing them if the patient has BC, Medicare, or Cigna. I won’t bother with patients on Aetna or UHC.

I understand that BC is a crapshoot based on the different versions, but might as well refer those folks.
 
bedrock said:
Thank you all.

Going forward I will refer intracept cases to the only guy in the state doing them if the patient has BC, Medicare, or Cigna. I won’t bother with patients on Aetna or UHC.

I understand that BC is a crapshoot based on the different versions, but might as well refer those folks.
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You can also ask that doc what he charges for self-pay. I have seen it vary widely from 12-25k. I strongly discourage patients from doing that as the results are not guaranteed, but some with the means and clear understanding of outcome percentages are still open to it.
 
bedrock said:
Thank you all.

Going forward I will refer intracept cases to the only guy in the state doing them if the patient has BC, Medicare, or Cigna. I won’t bother with patients on Aetna or UHC.

I understand that BC is a crapshoot based on the different versions, but might as well refer those folks.
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There’s only 1 guy doing them in your state??
 
Regarding sedation vs GA -

I have done two cases under very light sedation. Young patients with thick hard bone - used a mallet.

Generous medial branch blocks (1+ ml per level) is the key I think. Also did periosteal lidocaine.

One guy was pretty wiggly during the burn that required some propofol bumps (first care). Second case - no movement at all but this time CRNA used a small amount of ketamine.
 
From intracept training, only 15-20 degree rotation is needed for S1 insertion, is it reasonable? Thanks.
 
SC Tian said:
From intracept training, only 15-20 degree rotation is needed for S1 insertion, is it reasonable? Thanks.
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I think ~35 degrees gets you to the 40 yard line most consistently. But if you are aggressive with the retraction method and stay pretty posterior before starting the curve then those angles may work.
 
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RoloTomassi said:
I think ~35 degrees gets you to the 40 yard line most consistently. But if you are aggressive with the retraction method and stay pretty posterior before starting the curve then those angles may work.
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If iliac crest w head tilt gives you less than that angle I’d also rec starting w bevel tip stylet.
 
Doing my 1st S1 tommorrow.


I have done about 8. 4 of the pts are 90 to 100% better. 1 failure. Others about 50%.

Overall safe. Just don't know about s1
 
Taus said:
If iliac crest w head tilt gives you less than that angle I’d also rec starting w bevel tip stylet.
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The new training did mention starting with bevel tip first.
 
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