Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Pain.
Treatment: Peripheral Nerve Stimulator.
The insurer denied the peripheral nerve stimulator.
The health plan's determination is upheld.

The patient is a female who is diagnosed with leg pain. The records provided show that a request for peripheral nerve stimulation treatment was denied by the insurance carrier as experimental and investigational as this treatment has not been shown to be effective for the patient's condition.
There is a letter of appeal from the provider stating that they disagree with denial of the SPRINT peripheral nerve stimulator to the left sciatic nerve and left superior cluneal nerve. It was stated that the patient has a history of diagnoses including spondylosis of thoracolumbar spine, left-sided piriformis syndrome, hypovitaminosis D, hyperparathyroidism, age-related osteoporosis without current pathological fracture, lumbar radiculopathy, left leg pain and fibrocystic disease of the breast. It then states the patient has a history of left-sided piriformis syndrome, neuralgia, lumbar radiculopathy and complex regional pain syndrome type I of the left lower extremity (left sciatic nerve). The patient presents with chronic left lower extremity pain localized to the left gluteal region that radiates down the posterior lateral aspect of the thigh to the ankle. The patient endorses weakness in the left leg that is chronic and unchanging. The physical examination was notable for piriformis tenderness and reduced strength at 4 out of 5 to the left hip flexor. The provider states that the pelvic magnetic resonance imaging (MRI) shows minimal narrowing of both hip joints without significant degenerative changes and minimal bilateral gluteus medius/minimus insertional tendinosis. The lumbar MRI did not show any significant disc herniation or narrowing. The electromyography (EMG) was negative. The left piriformis and sciatic nerve injection provided 50 to 70 percent (%) relief that lasted only 3 days. It was noted that it is their medical opinion was that the patient should receive the SPRINT peripheral nerve stimulator to the left static nerve and left superior cluneal nerve due to refractory pain, difficulty performing activities of daily living and failed multidisciplinary conservative treatment.

The requested health service/treatment of placement of a peripheral nerve stimulator is not medically necessary for this patient. This treatment was previously denied on a prior review as experimental and investigational and the provider is appealing this determination. According to the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, "Not recommended, including several terms and device variations including percutaneous neuromodulation therapy (PNT), peripheral nerve stimulation (PNS), and peripheral nerve field stimulation (PNFS)...Evidence Summary - Available systems include but are not limited to:  SPRINT Peripheral Nerve Stimulation System,  StimQ Peripheral Nerve Stimulator and the StimRouter Neuromodulation System. Overview: While it has been suggested that peripheral nerve stimulation may augment or be a monotherapy for pain treatment, there are still gaps in knowledge requiring further research. Data on these techniques has been limited to case reports, retrospective reviews, and small case series, primarily for occipital nerve stimulation for chronic migraine headache." Records indicate the patient has a history of chronic pain in multiple body parts with neuropathic pain in the left lower extremity that has failed to respond to conservative treatment. However, peripheral nerve stimulation including the SPRINT PNS system is considered experimental and investigational as there is insufficient evidence found in the peer-reviewed medical literature with large studies showing the overall safety and efficacy of this treatment.