Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Postherpetic neuralgia.
Treatment:  Peripheral electrical nerve stimulator.

The insurer denied coverage for the peripheral electrical nerve stimulator.  The denial is overturned. 

This is a male patient with a history of arthritis, postherpetic neuralgia, abdominal complex regional pain syndrome, and spinal stenosis.  The patient presented to an office visit with a Pain Medicine Specialist for a follow-up for an acute flare up of his underlying chronic low back pain and postherpetic neuralgia pain.  He underwent Peripheral Trial Nerve Stimulator implantation of Left Transversus Abdominus Plexus and Anterior Abdomen with 2 leads and Peripheral Trial Nerve Stimulator implantation of Lower Left Thoracic Intercostal nerves with 2 leads.  He tolerated the procedure well, and there were no complications reported. 

According to Billet et al., peripheral nerve stimulation of primary afferent neurons provides control of localized chronic pain.  Subcutaneous placement of electrodes with minimally invasive technique and wireless neuromodulation technology was safe and effective.  Significant improvements in pain relief ensued, and no further adverse events had been reported at the end of 3 months' follow-up.

As per Nayak et al., "peripheral nerve stimulation has been used in the treatment of several chronic pain conditions including pain due to peripheral nerve dysfunctions, complex regional pain syndrome, and cranial neuralgias.  It has been shown to be effective for chronic, intractable pain that is refractory to conventional therapies such as physical therapy, medications, transcutaneous electrical stimulations, and nerve blocks.  Recently, a new generation of peripheral nerve stimulation devices has been developed; these allow external pulse generators to transmit impulses wirelessly to the implanted electrode, and their implantation is significantly less invasive."  
  
Per peer-reviewed literature, abdominal pain is a common disease state that affects millions of people globally.  Unlike other painful areas of the body, pain in the abdomen can be visceral or somatic, and even further, with viscerosomatic convergence, the presentation can be very complex.  Many patients suffer from pain of the anterior abdominal wall after surgical procedures, such as hernia repairs, cesarean sections, cholecystectomy, appendectomy, bowel surgeries, and from chronic conditions, such as endometriosis.  Furthermore, after multiple abdominal surgeries, adhesions may form within the tissues of the abdominal wall leading to localized neuropathic pain.  This neuropathic pain is secondary to nerve entrapment or direct nerve trauma.  Treatment of such painful conditions is often difficult and complex.  Recently, transversus abdominis plane blocks with local anesthetic have been utilized to treat such painful conditions.  This method, although often efficacious temporarily, is not seen as a long-term solution in most cases.  More definitive pain relief of anterior abdominal pain may be achieved by implantation of a neurostimulator (Haider et al.). 

In this case, the patient has history of arthritis, postherpetic neuralgia, abdominal complex regional pain syndrome, and spinal stenosis.  He has exhausted all possible medicine and/or other procedures that were listed as potentially beneficial.  The patient states that the trial was very helpful and relieved the pain, both anteriorly and posteriorly.  Since this patient's pain control is refractory to all the measures tried, and since he had a successful trial with neurostimulator, the literature review supports that this patient was a good candidate for the peripheral electrical nerve stimulator.     

Thus, the requested service was likely to be more beneficial than any of the standard treatments/procedures for this patient.  

The carrier's denial of coverage for the peripheral electrical nerve stimulator should be overturned.