Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cervicalgia  
Treatment: 64575 (incision for implantation of neurostimulator electrodes; peripheral nerve; excludes sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures)  

The insurer denied the 64575 (incision for implantation of neurostimulator electrodes; peripheral nerve; excludes sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures).  

The denial was reversed.  

Reviewer # 1:  

This is a male patient with a history of cervicalgia and cervicogenic headaches. It was reported that the patient developed his condition after a febrile episode in which he underwent a lumbar puncture. Post procedure he developed low pressure headaches.  

There is ample scientific evidence to support improvement in health outcome for this service.  Due to the low percentage of the population with this diagnosis, large studies are difficult and depend on smaller studies.  There are many small studies that show it is a safe and effective treatment.  While they are considered to be in a Level III category, there is enough conclusive evidence for consideration of treatment for a particular set of patients.  

Staudt, et al states, "Occipital nerve stimulation (ONS) is a nondestructive form of neuromodulation that involves the percutaneous placement of electrodes in the region of the greater, lesser, and/or third occipital nerves.  ONS is commonly used in the treatment of occipital neuralgia and chronic migraines; however, its use has been described in various craniofacial pain syndromes.  The therapeutic benefit of ONS for the treatment of diverse headache presentations and pain distributions may be explained by the functional convergence between occipital nerve and meningeal afferents in the upper spinal cord, termed the trigeminocervical complex.  For patients with medically refractory occipital neuralgia or other craniofacial pain syndromes, ONS is a minimally invasive, reversible, and adjustable alternative to other ablative therapies including occipital neurectomy, C2 ganglionectomy, and rhizotomy...." (1)  

Choi, et al states, "Recently, successful results with ONS have been reported in the management of intractable headaches, including cervicogenic headache, ON, transformed migraine, hemicrania continua, and cluster headaches.  This stimulation technique involves the subcutaneous insertion of electrodes in the C1-C2 region of the posterior cervical spine.  Convergence of afferents from C1-C3 cervical nerves with trigeminal afferents is explained as the cause of the cervicogenic headache that results from activation of these nerves.  The pain control mechanism of ONS is similar to that of gait control theory, considered in other peripheral nerve stimulation.  As opposed to destructive surgery, ONS is fully reversible. If the patient does not want to use stimulation, it is easy to stop the stimulation and the device can be removed with a simple procedure." (4)  

The requested trial and possible permanent placement of PENS for this patient who has intractable pain despite treatment would be likely to be more beneficial than any other standard treatment for this patient.  The Congress of Neurological Surgeons concludes that occipital neurostimulation is a treatment option for patients with medically refractory occipital neuralgia and there are clinical guidelines by Medicare.  The service is low risk and easily reversible.  

The carrier's denial of procedure codes 64575 (incision for implantation of neurostimulator electrodes; peripheral nerve; excludes sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures) should be reversed.