Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pain Management. 
The insurer denied Percutaneous Peripheral Nerve Stimulation (PNS). 
The denial is upheld. 

This is a female patient, noted to have a history of chronic shoulder pain, diagnoses listed on the progress note were lumbar radiculopathy and lumbar intervertebral disc disorders with radiculopathy. Records indicate the patient has a history of chronic shoulder pain. The treating provider recommended the patient undergo peripheral nerve stimulation (PNS) implantation, which was denied by the health plan as experimental and investigational. This denial is under appeal.
There is a letter of appeal from the provider stating that they are looking for ways to improve the patient's chronic pain without increasing medications or relying on invasive permanent procedures such as a spinal cord stimulator implant. The provider states that peripheral nerve stimulation is the next step in the patient's continuum of care. The provider states they are requesting approval for a one stage implantation of peripheral nerve stimulation leads with the Sprint system and is requesting reconsideration for approval of this procedure.
Progress report stated the patient presented with complaints of shoulder pain and it was noted last clinic visit was a new patient. The patient complains of pain in the right shoulder with joint stiffness, decreased range of motion, and pain rated at 9/10. It was stated that the pain resulted from a fall on the street. Medications included alprazolam, Abilify, meloxicam, Quetiapine, Ambien, and lamotrigine. A physical exam was not performed. The plan was for peripheral nerve stimulation for the right shoulder pain.
At issue is the medical necessity of Percutaneous Peripheral Nerve Stimulation (PNS).

The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Percutaneous Peripheral Nerve Stimulation (PNS) is not medically necessary for this patient.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, "Not recommended, including several terms and device variations including percutaneous neuromodulation therapy (PNT), peripheral nerve stimulation (PNS), and peripheral nerve field stimulation (PNFS)...Evidence Summary - Available systems include but are not limited to: 
1) Sprint Peripheral Nerve Stimulation System (SPR Therapeutics, Cleveland, Ohio) 
2) StimQ Peripheral Nerve Stimulator (Stimwave Technologies Incorporated, Ft. Lauderdale, FL) 
3) StimRouter Neuromodulation System (Bioness, Inc., Valencia, CA). 

Overview: While it has been suggested that peripheral nerve stimulation (PNS) may augment or be a monotherapy for pain treatment, there are still gaps in knowledge requiring further research. Data on these techniques has been limited to case reports, retrospective reviews, and small case series, primarily for occipital nerve stimulation for chronic migraine headache."
According to the progress note the patient had complaints of two-week onset of shoulder pain from a fall. The provider recommended the patient undergo peripheral nerve stimulation. However, there was no physical exam performed at that visit and no documented failure of first-line evidence-based treatments. Peripheral nerve stimulation is not recommended including the Sprint PNS system due to lack of evidence and this treatment is considered experimental and investigational. This service is not medically necessary as there is no documentation of first line treatments.
Therefore, the requested health service/treatment of Percutaneous Peripheral Nerve Stimulation (PNS) is not medically necessary.