Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 30-year-old female with a history of chronic headache pain diagnosed as occipital neuralgia. The patient reports her symptoms first occurred subsequent to surgical resection of  an osteoma in 1996. Various oral medications such as Darvocet, Imitrex, gabapentin, Vicodin, Fioricet and Ultram have been tried. While somewhat effective, in most cases the degree of the pain relief has been limited by the occurrence of side effects. No other oral medication trials are described. Radiofrequency neural thermocoagulation was suggested by the patients provider, but the treatment was not authorized. The current recommendation of the patients provider is for placement of an occipital nerve stimulator. The Health Plan considers the procedure experimental/ investigational, and has denied the request for authorization.The patient has a history of refractory headaches dating back to her osteoma resection. The record did not include a detailed neurological evaluation, and the basis for her diagnosis of occipital neuralgia is not entirely clear. Previous treatment with Imitrex suggests that migraine may have also been considered diagnostically. The record indicates that occipital nerve blocks have been helpful for symptom relief. Occipital nerve blocks have been shown to be effective in the treatment of migraine and cluster headaches as well as occipital neuralgia. Thus the positive response does not constitute proof of occipital neuralgia. Numerous other treatments exist for neuropathic pain conditions such as carbamezapine and pregabalin, which do not appear to have been tried. For migraine as well, there are numerous preventive treatments such as topiramate or divalproex which do not appear to have been tried. A full neurological consultation should be performed to clarify the diagnosis, and other, standard therapies might successfully be pursued.Although a search of the literature identified some anecdotal evidence of occipital nerve stimulation (ONS) being used successfully for treatment of occipital neuralgia, no clinical on this topic were discovered. ONS is also being studied for refractory migraine and refractory cluster headache, but has not yet been established as beneficial for these conditions either. In summary, occipital nerve stimulation has not been found to be safe or effective for either occipital neuralgia or migraine headache. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  This patient is a 30-year-old female diagnosed with occipital neuralgia. She is currently treated with pain medications and monthly occipital nerve blocks. It appears that she does obtain some symptom relief from the nerve blocks, but would prefer a more definitive treatment approach. The enrollees provider has recommended that she undergo placement of an occipital nerve stimulator. The Health Plan denied authorization and coverage for this procedure on the basis that it has not been shown to be efficacious in the treatment of occipital neuralgia.The record indicates the patients condition has responded to occipital nerve blocks. Understandably, she finds the side effects of the pain control medications to be problematic. However, there is a wide variety of medications that have not been tried and  may be effective for this type of pain such as Tegretol, Cymbalta, Lyrica or Elavil. Occipital nerve stimulation is an experimental treatment currently undergoing clinical trials. There is minimal literature on the topic; what does exist is primarily open-label, retrospective case reports or small case series. Occipital nerve stimulation is not indicated for this patient, as clinical trials are on-going and the safety and efficacy of the therapy has not been established.Based upon the information set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 30-year-old female status post osteoma excision from the right parietal bone, and diagnosed with occipital neuralgia. She has been treated with various medications and monthly occipital nerve blocks, but reports persistent pain. Her pain management specialist initially recommended a neural radiofrequency thermal coagulation procedure, which was denied by the Health Plan. A subsequent request for authorization of an occipital nerve stimulator was also denied by the Health Plan citing the investigational nature of the procedure. Occipital neuralgia is a condition characterized by frequent paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The pain is usually unilateral but may be bilateral and may spread towards the vertex. The episodes can last for days, making even routine daily tasks difficult to accomplish. The treatment plan for occipital neuralgia/occipital headache depends upon many factors, such as the severity of the pain, degree of dysfunction, type of pain, location of pain, the patients age, the patients ongoing medical conditions and the patients ability to tolerate other medical therapies. Standard therapy may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage.While studies such as the one conduced by Kapural and others suggest that occipital nerve stimulation may, at some point, provide a viable alternative to irreversible neuroablative therapies, it remains an unproven procedure at this time. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear; further study is needed. As such, the procedure cannot be recommended at this time. Accordingly, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.