Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pudendal nerve stimulation with StimWave neuromodulation (Phase 1  percutaneous implantation of neurostimulator electrode, peripheral nerve and Phase 2  insertion/replacement of peripheral neurostimulator pulse generator or receiver. In the medical literature, Murer and colleagues evaluated current studies on the treatment options available for patients with pudendal neuralgia (PN). The authors concluded that, Although there are a number of modalities utilized for the treatment of PN, there are no current recommendations based on treatment efficacies. Fang and colleagues reported on 80 patients with pudendal neuralgia who were treated with pulsed radiofrequency and pudendal nerve block or nerve block alone. The authors found that, Compared with the single nerve block treatment, pudendal nerve pulsed radiofrequency combined with nerve block could provide more long-lasting relief from pain symptoms of pudendal neuralgia. Furthermore, Roberts and colleagues reported on 13 patients treated with StimWave lead placed at the pudendal nerve who reported that nine underwent permanent lead placement given greater than 50% improvement in pain. The records provided for review document that this patient has failed reasonable conservative care measures and is a candidate for pudendal nerve stimulation with StimWave. Neuromodulation is less invasive than surgery, is accompanied with fewer risks, and is supported for use in patients with pudendal neuralgia who have failed conservative treatment. For these reasons, the requested pudendal nerve stimulation with StimWave neuromodulation (Phase 1  percutaneous implantation of neurostimulator electrode, peripheral nerve and Phase 2  insertion/replacement of peripheral neurostimulator pulse generator or receiver is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.