Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder-Headaches
Surgical Services

The patient is a female with a complicated past neurosurgical medical history that started with ventriculitis at age 3 weeks resulting in hydrocephalus and eventually the first of many ventriculoperitoneal shunts. She has had many shunt revisions over the years, including several replacements for infections, the last of which appears to have been in. She currently has 3 shunts - 2 in the bilateral occipital regions and one in the right frontal region. She has severe refractory headaches involving the entire right side of her head, which the provider feels is radiating from the right occipital region. There is a neurology note from that stated greater and lesser occipital nerve blocks in did not help but another more recent note from stated that an occipital nerve block provided dramatic relief for 24-36 hours - further details as to when the block took place was not documented. Other measure to ameliorate her symptoms have included sphenopalatine blocks, Botox and medications which have failed. Her neurological exam is always recorded as normal and no note mentions any occipital notch tenderness. There are no notes of other conservative measures such as physical therapy (PT)/chiropractic measures.

Notes state that the patient has had many shunt revisions over the years, including several replacements for infections, the last of which appears to have been 4 years ago. She currently has 3 shunts - 2 in the bilateral occipital regions and one in the right frontal region. She has severe refractory headaches involving the entire right side of her head, which the provider feels is radiating from the right occipital region. There is a neurology note that stated greater and lesser occipital nerve blocks in 2 years prior did not help but another more recent note  stated that an occipital nerve block provided dramatic relief for 24-36 hours - further details as to when the block took place was not documented. Other measure to ameliorate her symptoms have included sphenopalatine blocks, Botox and medications which have failed. Her neurological exam is always recorded as normal and no note mentions any occipital notch tenderness. There are no notes of other conservative measures such as physical therapy (PT)/chiropractic measures.
Her neurosurgeon has declined to consider occipital nerve stimulation due to the shunt hardware and concern for complications. The current pain management provider has recommended a right ONS (occipital nerve stimulation) trial, although in the last note provided he was referring the patient to be considered for radiofrequency ablation therapy. No follow-up from that is provided.

The health plan's determination is upheld.

It has not been convincingly demonstrated that the patient's refractory pain is indeed from right occipital neuralgia (ON). There is one reference to a successful nerve block, but no further details are available as to when this took place, as well as a notation that a similar block in 2016 was not successful. There is no record in the clinical examinations of right occipital notch pain to palpation. There is no record of a trial of a therapeutic right occipital nerve injection with corticosteroids or attempted conservative measures with physical therapy to alleviate the symptoms.

The requested health service/treatment for an ONS trial is not medically necessary for this patient at this time. There is no convincing evidence that her pain emanates from the right occipital nerve. There appears to have been one diagnostic block at some point referenced in the note but no details are given, and it apparently has not been repeated for verification. No therapeutic blocks of the right occipital nerve with corticosteroids, which can be very beneficial and repeatable, have seemingly been performed. The presence of the shunt hardware and the concern for introducing an infection with another foreign body implant, particularly given that she has had shunt infections in the recent past, make consideration for radiofrequency ablation (RFA) of the right occipital nerve preferable to ONS. This was actually recommended as an alternative treatment by the provider in his note although no follow-up to that referral is available for review.

While there is level III evidence to support the efficacy of ONS for refractory occipital neuralgia (ON), there have been no randomized controlled trials to determine the optimal treatment for ON (Burchiel et al. and Sweet et al.). A review of the literature does suggest that, with appropriately selected patients, ONS can effectively decrease pain and medication use for patients with medically refractory ON. (Banks et al, Keifer et al and Slavin et al). However, this patient has not conclusively been diagnosed with ON.