Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain
Treatment: Durable Medical Equipment (DME)/Neurostimulator
The health plan denied the requested neurostimulator as not medically necessary. 
The health plan's determination is upheld.

The patient is diagnosed with low back pain. Records indicate that the treating provider recommended the patient for a SPRINT neurostimulator, which was denied as experimental and investigational. There is a letter of appeal from the provider stating that denial of the peripheral nerve stimulation is not consistent with currently accepted medical practice. The provider notes that they are requesting approval for a one stage implantation of peripheral nerve stimulation with the SPRINT PNS system and states that this device has been studied extensively. The provider states the patient suffers from bilateral low back pain and her pain is chronic, intractable and traumatic. She currently experiences decreased range of motion with sharp, stabbing, burning, aching pain and reports feeling weakness in the back muscles. She has tried physical therapy, home exercise program, multiple steroid injections, multiple radiofrequency ablation, nerve blocks, trigger point injections, over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), and pharmaceutical therapies, but pain and functional limitations persist. The provider states that without approval of this treatment the only other options are invasive and/or permanent. 
At issue is the medical necessity for the requested Neurostimulator.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of a Neurostimulator 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." Records provided indicate the patient has a history of chronic back pain and the patient was noted to have decreased range of motion. She has tried physical therapy, home exercise program, multiple steroid injections, multiple radiofrequency ablation, nerve blocks, trigger point injections, over-the-counter NSAIDs, pharmaceutical therapies but pain and functional limitations persist. It is noted that a magnetic resonance imaging (MRI) of the lumbar spine showed severe spondylosis at all levels from (lumbar) L1 - L2 through L5 - (sacral) S1 and varying degrees of facet arthrosis. It is unlikely that his treatment would result in any significant or sustained improvement in the patient and is likely a potential surgical candidate. The requested procedure remains experimental and investigational and is not considered standard of care treatment in the general medical community. Medical necessity is not established.