Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Occipital Neuralgia

Treatment: Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575)

The insurer denied coverage for Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575)

The denial is overturned 

Reviewer #2:

The magnetic resonance imaging (MRI) brain taken showed left ventricle is larger than the right, and a serpiginous area of enhancement is noted in the left posterior frontal/parietal region. No cerebellopontine mass or lesion is identified and nerves 7 and 8 are normal.

Studies exist that suggest use of the occipital nerve stimulation device provides an improvement in health outcomes.

The patient recently had left suboccipital craniotomy x3.  The patient has been engaged in physical therapy (PT) and has tried high dose medical therapy and has also tried the Cefaly device without relief.

Both of the patient's providers confirm that the claimant has disabling facial and occipital pain and has not improved despite medical therapy and several surgical procedures and suboccipital nerve block.  

Therefore, the records establish that neuromodulation in such a case of severe refractory pain does result in improvement in health outcome.

Fogel, H. P., & Winfree, C. J. (2022), "Peripheral nerve stimulation (PNS) is a powerful interventional option for the management of otherwise intractable pain. This technique involves the implantation of electrodes to apply electrical stimulation to named peripheral nerves, thereby alleviating pain in the territory of the target nerves. Recent advancements, largely driven by physician-industry relationships, have transformed the therapy into one that is minimally invasive, safe, evidence-based, and effective. Ongoing research has expanded the indications beyond chronic neuropathic pain in a peripheral nerve distribution. This article provides an overview of recent advances in this field."

Since the patient had left suboccipital craniotomy without relief, and since the patient had some relief after the occipital nerve block performed, and since the studies cited below suggest that neuromodulation is safe and effective, the use of the proposed nerve stimulation devices and related trials are medically necessary, and these devices are approved by the appropriate regulatory bodies.     

This patient is a good candidate for Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575).

Given the severe pain noted in the records and the failure of other treatment modalities including the Cefaly device and high dose medical therapy and serial surgical interventions, and since these measures have not provided durable relief, the occipital and trigeminal nerve stimulation devices are the best available treatment for this patent at this time.     

Standard treatments and services have not provided relief and therefore the risks of treatment are acceptable.     

In summary, the denial of Occipital Nerve Stimulation device and Trigeminal Nerve Stimulation device (procedure codes 64555, 64590 & 64575) and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.