Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic pain
Issue under review:  Neurostimulator implantation surgery

Determination:
The health plan should cover the Neurostimulator implantation surgery.

The patient is an adult female with history of chronic low back pain radiating to the left lower extremity.  She has past history of thoraco-lumbar decompressive surgery with evidence of myelopathy and myelomalacia.  She was diagnosed as having chronic neuropathic pain syndrome and T11 AIS (ASIA impairment scale) type D spinal cord injury.

The patient has failed subsequent conservative management measures, including physical therapy, Reiki, Massage, NSAIDs (nonsteroidal antiinflammatory drugs), opioid medication, anti-neuropathic pain medications (five different types), several spinal injections, etc.

The proposed DRG-Spinal Cord Stimulator is medically appropriate, as the patient has exhausted all conservative measures.  The patient has also met national standard criteria, including indication of post-thoraco-lumbar laminectomy syndrome, chronic neuropathic pain secondary to thoracic myelopathy with T11 AIS type D spinal cord injury, failed conservative measures as stated in clinical summary, and also recommendation to proceed with the SCS trial after Neuropsychological evaluation.

The guidelines for Spinal Cord/Dorsal Column Stimulation Insertion are in line with general clinical practice as written under the 2018 Interqual Procedures criteria for Spinal Cord Stimulator insertion and in line with national recommendations, which state that spinal cord stimulators be reserved for patients who have failed conventional treatments and met the following criteria:
Electrical nerve stimulation:
Neuromodulation with electrical stimulus:  1)  Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies, 2)  Spinal cord stimulation may also be considered for other selected patients (e.g., CRPS, peripheral neuropathic pain, peripheral vascular disease, and post-herpetic neuralgia), 3)  Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement, 4)  A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device.

In this instance, the target area of Dorsal Root Ganglion stimulator is within national standard of care, and the procedure is FDA-approved for such purpose in a patient with history of chronic low back pain radiating to the left lower extremity with past history of thoraco-lumbar decompressive surgery with evidence of myelopathy and myelomalacia and diagnosed as having chronic neuropathic pain syndrome and T11 AIS type D spinal cord injury.

The patient failed subsequent conservative management measures, including physical therapy, Reiki, Massage, NSAIDs, opioid medication, anti-neuropathic pain medications (five different types), several spinal injections, etc. In addition, she had a neuropsychological assessment that concluded that she is a good candidate for the SCS trial.