Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Occipital Neuralgia

Treatment: Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575)

The insurer denied coverage for Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575)

The denial is upheld 

Reviewer #1:

The patient has a history of Occipital Neuralgia. The claimant complains of persistent left trigeminal neuropathic syndrome. The patient has current pain described as flickering, stabbing, sharp, gnawing, tugging, stinging, dull, exhausting, fearful, cruel, miserable, penetrating, dreadful and horrible. The patient has had 8/10 level of pain for the past week. The patient has failed best medical management. The pain is severe, intractable, and interfering with their quality of life and activities of daily living.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Neurostimulation or Electrical Stimulation for Headaches/Occipital Neuralgia requires further investigation by higher powered study. Further controlled studies to validate the use of neurostimulation for this patient are clearly warranted. Follow-up regarding both short and long-term effectiveness of neurostimulation or electrical stimulation for treatment of migraine still needs to be assessed. Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Tao et al. (2018) conducted a meta-analysis to analyze the effectiveness and safety of transcutaneous electrical nerve stimulation (TENS) on patients with migraine. The study included four randomized controlled trials, which compared the effect of TENS (n=161) with sham TENS (n=115). Change in the number of monthly headache days, responder rate, painkiller intake, adverse events and satisfaction were extracted as outcome. The authors concluded that there is low quality evidence suggesting that TENS may be effective in increasing responder rate, reducing headache days and painkiller intake, serving as a well-tolerated alternative for migraineurs. Future well-designed randomized controlled trials (RCTs) with extensive follow-up are needed.

A prospective, long-term, open-label, uncontrolled observational study to evaluate the long- 

Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575) does not have final approval from the appropriate regulatory bodies for this diagnosis.     

The claimant is not a good candidate for Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575).     

Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575) is not the best available treatment for this patient at this time.     

There are substantial risks associated with the risk of the occipital nerve stimulator.     

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

In summary, the denial of Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are/are not substantially increased over standard treatments.