Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Complex Regional Pain Syndrome (CRPS).

Treatment: Procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation [PNS]).

The insurer denied coverage for procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation).  The denial is upheld.

The patient was seen with chronic left leg pain due to complex regional pain syndrome (CRPS).  The patient has leg pain allodynia, swelling, temperature changes. The patient was scheduled for ketamine infusions. The pain is in the left foot and radiates up towards the left thigh.  He has relief with his dorsal root ganglion (DRG) setting without adverse effects.  Multiwave Locked System (MLS) and ketamine were scheduled.  The DRG was noted to become less effective recently.  Exam demonstrates mild left lower extremity weakness due to pain.  There is allodynia on the lateral left foot to the thigh. Range of motion (ROM) of the back is decreased.  Plan was to schedule a 2-lead peripheral nerve trail for CRPS. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

The requested service, 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation) is considered unproven for the treatment of CRPS.  There is insufficient evidence to support its use.  Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Prasad M.D., A., & Chakravarthy M.D., K. state, "Increasing evidence supports a role for inflammation and neuroinflammation in CRPS pathophysiology. Preliminary neurostimulation findings, together with the role of (neuro) inflammation in CRPS, seems to provide a compelling rationale for its use in CRPS pain treatment. The possible immunomodulatory effects of neurostimulation opens new therapeutic possibilities, however further research is needed to gain a better understanding of the working mechanisms."

This procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation) does have final approval from the appropriate regulatory bodies for this diagnosis.     

The patient is not a good candidate for procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation). 

The procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation) is not the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The insurer's denial of coverage for procedure code 64555 - Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (Sprint Peripheral Nerve Stimulation) is upheld.