Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Occipital neuralgia
Treatment: Occipital nerve stimulation
The health plan should not cover the occipital nerve stimulation.

Clinical studies are inadequate to show efficacy of occipital nerve stimulation. Clinical literatures attached to the appeal letter include a small number of patients with no large randomized clinical trial to show effectiveness of occipital nerve stimulation.

In 2006, Johnstone CSH et al. found that occipital stimulation is a reversible treatment of intractable occipital neuralgia. There are pitfalls of lead migration, sepsis, opiate dependency.

On 05/08/2014, Dach F et al. found that block of greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in treatment of cluster headaches; controlled studies are still necessary to clarify real role of peripheral nerve block.

On 10/27/2014, Dillie E et al. conducted a randomized study of 69 patients stating that occipital nerve block (ONB) does not reduce frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. 

On 06/04/2015, Sweet JA et al. conducted a literature review stating that use of occipital nerve stimulation (ONS) is a treatment option for patients with medically refractory occipital neuralgia (ON) with Level III evidence.

On 05/23/2016, Cuadrado ML et al. found that greater occipital nerve (GON) blocks appear to be effective in the short term in chronic migraine. GON block followed by an increase in pressure pain thresholds in trigeminal area suggests an effect on central sensitization at the trigeminal nucleus caudalis.

The American Society of Anesthesiologists' Practice Guidelines on Chronic Pain Management states that the literature is suggestive of the analgesic benefit effects, but is equivocal regarding the beneficial or adverse effects, of peripheral nerve stimulation. 

A Medline search of peer-reviewed literature failed to locate large, randomized, double-blinded clinical trials that permit conclusions about the efficacy and long-term benefit of peripheral implanted nerve stimulation for treatment of pain.

Corriveau et al. in 2019 found nerve stimulation is a reversible technique that is used successfully for the treatment of traumatic neuropathic pain, complex regional pain syndrome, and craniofacial neuropathic pain. Nerve field stimulation targets painful regions rather than a single nerve and has expanded indications, including axial low back pain. Appropriate patient education and motivation are crucial prior to surgery. Ongoing research is necessary to provide high-level evidence for the use of nerve stimulation. Most electrodes are primarily designed for spinal cord stimulation, hence the need to develop nerve electrodes dedicated for nerve stimulation.

Trent et al. in 2019 found percutaneous peripheral nerve stimulators have been used for chronic neuropathic pain in patients with contraindications to spinal cord stimulators, and permanent lead placement has been the choice for chronic neuropathic pain. In addition, post-operative pain control may be achievable using peripheral nerve stimulation. The uses of peripheral nerve stimulators have not yet been fully explored, but several studies suggest that this technique is a feasible adjunct to current pain management practices.

The requested health service or procedure is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

The patient has cervicogenic headaches, diagnosed an MD and suggested by the PA, from broad-based disc bulge at C5-6 found on MRI of cervical spine, above previous fusion at C6-7. The patient may benefit from treatment of the C5-6 disc bulge for relief of cervicogenic headaches.