Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 3: 

This is a male patient who was diagnosed with occipital neuralgia and cervicalgia with associated muscle spasms and associated cervicogenic headaches. It was reported that the patient developed his condition after having a febrile episode followed by a lumbar puncture. He was treated with a course of antibiotics and later developed low-pressure headaches. Despite being ruled out a spinal leak he developed sever occipital headaches and persistent neck pain. He has been treated with Celebrex, Flexeril, trigger point injections, acupuncture, and physical therapy, with little relief. He has had an occipital nerve block with a cervical epidural with no relief. A request for an occipital nerve stimulator trial was made to manage his chronic pain. 

Literature states occipital nerve stimulation (ONS) is a form of neuromodulation therapy aimed at treating intractable headache and craniofacial pain. Typically, candidates for successful ONS include those patients with migraines, Chiari malformation, or occipital neuralgia. In this case, the patient has occipital neuralgia. The patient's pain was refractory to greater occipital nerve blocks, epidural blood patch, epidural block, and medications. Therefore, occipital nerve stimulation (ONS) would be appropriate in this patient's clinical scenario. The scientific evidence and peer-reviewed literature support a result of improvement in health outcomes. The procedure codes 64575 (see incision for implantation of neurostimulator electrodes; peripheral nerve; exclude sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures) have final approval from the appropriate regulatory bodies for this diagnosis. This procedure meets the standard of care and is regularly performed. This patient is a good candidate for procedure codes 64575 (see incision for implantation of neurostimulator electrodes; peripheral nerve; exclude sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures) as he has been diagnosed with occipital neuralgia and has failed extensive conservative management. Procedure codes 64575 (see incision for implantation of neurostimulator electrodes; peripheral nerve; exclude sacral nerve) and 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures) are the best available treatment for this patient at this time. Peripheral occipital nerve stimulation is the only available treatment that is likely to alleviate his symptoms. 

Occipital nerve stimulation (ONS) is a form of neuromodulation therapy aimed at treating intractable headache and craniofacial pain. The therapy utilizes neurostimulating electrodes placed subcutaneously in the occipital region and connected to a permanently implanted programmable pulse generator identical to those used for dorsal column/spinal cord stimulation. The presumed mechanisms of action involve modulation of the trigeminocervical complex, as well as closure of the physiologic pain gate. ONS is a reversible, nondestructive therapy, which can be tailored to a patient's individual needs. Typically, candidates for successful ONS include those patients with migraines, Chiari malformation, or occipital neuralgia (Mammis, et al, 2015). 

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.