Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Percutaneous peripheral nerve stimulation (PNS)
The insurer denied Percutaneous peripheral nerve stimulation (PNS).
The determination is upheld.

This is a patient with a diagnosis of low back pain. The records provided indicate the patient has a history of chronic intractable low back pain that failed to respond to traditional conservative treatment. The provider recommended that the patient undergo implantation of the SPRINT PNS system (peripheral nerve stimulation), which was denied by the health plan.

Letters of appeal are provided and outline that the provider is requesting approval for a one stage implantation of PNS leads targeting the peripheral nerves. It was noted the patient has had chronic left low back pain, worse on the left which radiates down the left leg, hip and lower extremity with paresthesias in the left thigh, calf and big toe. The pain is as severe as up to 8/10. It was noted that magnetic resonance imaging (MRI) shows foraminal narrowing and disc bulging at lumbar (L) 3 - L4 and L4 - L5 levels. They have attempted conventional treatment options but pain and functional limitations persist. It was stated that the MRI shows disc bulges at L3 - L4 and L4 - L5 abutting the exiting nerve roots as well as an annular tear and facet arthropathy present. It was stated that without approval of this treatment the only other options are invasive and/or permanent. At issue is the medical necessity of percutaneous peripheral nerve stimulation (PNS).

The requested health service/treatment of percutaneous peripheral nerve stimulation (PNS) is not medically necessary for this patient.

Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "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: Sprint Peripheral Nerve Stimulation System (SPR Therapeutics, Cleveland, Ohio), StimQ Peripheral Nerve Stimulator (Stimwave Technologies Incorporated, Ft. Lauderdale, Florida), StimRouter Neuromodulation System (Bioness, Inc., Valencia, California). 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." The records provided indicate that the patient has a history of chronic back pain radiating into the left lower extremity with paresthesias and MRI evidence of disc bulges abutting the exiting nerve roots at L3 - L4 and L4 - L5. The patient is also noted to have an annular tear as well as facet arthropathy present, all of which are likely contributing to the patient's chronic back pain. It was noted that the patient was recommended for the SPRINT PNS system. However, there is insufficient evidence evaluating long-term safety and efficacy of peripheral nerve stimulation and further studies are needed. The request is not medically necessary.