Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder 
Treatment: Surgical Services 
The insurer denied the nerve decompression. 
The denial is upheld.

The patient is a female with a long history of migraine headaches and right occipital nerve region pain. She has undergone multiples cervical spine surgeries with her last magnetic resonance imaging (MRI) in late 2019 reporting anterior cervical discectomy and fusion (ACDF) C3 to C7 and a posterior spinal fusion at C6-7. She also has had a right craniotomy for a ruptured arteriovenous malformations (AVM) in the past with residual right temporal encephalomalacia. Her medication regiment includes Ajovy injections every (Q) 3 months for migraine, Methadone, Mobic, muscle relaxants and Xanax. 

In 2018, after multiple right occipital nerve blocks resulted in transient relief of her right occipital region pain that radiated to her forehead, she underwent a right occipital neurectomy. The operative note describes the proximal greater occipital nerve to be encased in scar tissue. It was followed as proximally as possible then transected and implanted into muscle. The procedure was complicated by a postoperative infection which cleared with wound care and antibiotics. In the postoperative notes in 2018 the patient continued to complain of severe right occipital region pain, unrelieved by the procedure and only attained relief in the area of the incision at the occipital notch. There are references to possible neuromodulation for the persistent pain but there is no documentation that a trial was performed. She was recently seen again with the same intractable severe right occipital region pain. The surgeon noted that she continues to have no pain in the region of the prior surgery, but severe distal pain beyond the incision. He has recommended a re-exploration for further decompression of the occipital nerve. 

The question for this review is in regard to the potential benefit of this re-exploration for the patient. 

In this particular case the proposed nerve decompression treatment is not likely to be more beneficial than other possible treatments for the patient's disabling condition or disease. The reason for this assessment is that she has already undergone one failed attempt at this procedure, with relief only in the occipital notch area where the direct decompression and neurectomy was undertaken and not in the radiating occipital scalp region pain that has persisted ever since. Even immediately after surgery, when the optimal results should have been expected, the notes document that she continued to have persistent pain. This makes it extremely unlikely that further direct decompressive or ablative intervention of the right occipital nerve will yield any better results. 
Having said that, the patient does appear to be having intractable pain that has failed standard therapies and seems to require further intervention of some sort. There are no large randomized controlled trials, with or without blinding, to evaluate the multitude of treatment options for this difficult disease entity. The fact that there are so many potential treatment options for occipital neuralgia with or without migraine following failure of the standard approach of physical therapy and medical management (these include: neurectomy or decompression, radiofrequency ablation, neuromodulation, upper cervical dorsal rhizotomies, C2 ganglionectomy, etc.) is a testimony to the lack of an optimal treatment. However, the condition is rare and multifaceted, making the ability to recruit comparable patients into randomized studies in such numbers as to be statistically significant nearly impossible. Therefore, we must rely on meta-analyses and the existing small prospective studies for guidance towards best alternative to treatment when pain recurs or persists. There is a growing body of evidence that neuromodulation, as previously recommended by the surgeon, might be a treatment option. The Congress of Neurological Surgeons did report in 2015 that there was level III evidence to support the utilization of this modality in refractory patients (Sweet et al.) and this has been echoed by other authors (Slavin et al. and Burchiel et al.) although always with the call for further studies as there is a lack of evidence of long-term efficacy.