Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain
Treatment: Peripheral Nerve Stimulator
The insurer denied: Peripheral Nerve Stimulator
The denial is overturned

The patient is an adult male with history of chronic intractable low back pain of over 6 months. He has failed all conservative measures, including physical therapy, spinal injections, prednisone, lidocaine patch, Voltaren gel, trigger point injections, etc. He is unable to take oral NSAIDs (nonsteroidal anti-inflammatory drugs) due to chronic kidney disease. The patient's MRI (magnetic resonance imaging) of the lumbar spine 5 years ago showed multilevel lumbar foramina stenoses at L3/L4 and L4/L5 mostly.

The Peripheral Nerve Stimulator is medically necessary.

There is numerous evidence in the literature that neuromodulation with electric stimulus as subcutaneous/percutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with chronic pain syndrome who have not responded to other therapies, as evidenced in this case. Helm et al stated for PNS (peripheral nerve stimulation), "The evidence suggests that approximately two-thirds of patients with peripheral neuropathic pain will have at least 50% sustained pain relief. Adverse events from PNS [peripheral nerve stimulation] are generally minor. A major advantage of PNS [peripheral nerve stimulation] over spinal cord stimulation is the absence of any risk of central cord injury."
Xu et al stated for PNS (peripheral nerve stimulation), "Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS [peripheral nerve stimulation) in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain."
Deer et al stated for PNS (peripheral nerve stimulation), "Peripheral nerve stimulation was studied in 14 RCTs [randomized controlled trials] for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS [peripheral nerve stimulation] to treat pain."
Also, according to a class 1 study, percutaneous electrical nerve stimulation should be considered for the treatment of polyneuropathy for its effectiveness and improvement in quality of life. The study by Trent et al showed that percutaneous peripheral nerve stimulators have been used for chronic neuropathic pain in patients with contraindications to spinal cord stimulators, and permanent lead placement has been the choice for chronic neuropathic pain as evident in this case. In addition, the PNS (peripheral nerve stimulation) procedure is medically necessary as it is being used with prudent clinical judgment and would be provided to a patient in order to prevent or to evaluate or to diagnose or to treat an illness, injury, disease, or its symptoms. Additionally, the peripheral nerve stimulation would be furnished in accordance with generally accepted standards of professional medical practice; Clinically appropriate, in terms of type, frequency, extent, site, and duration; would be considered effective for the patient's illness, injury, or disease; consistent with the diagnosis and treatment of the patient's condition; not primarily for the convenience of the patient or his family and physician; consistent with the level of skilled services that are furnished and furnished in the least intensive type of medical care setting that is required by the patient's medical condition; and not more intensive than an alternative service or sequence of services at least as likely to produce the same therapeutic or diagnostic results to diagnose or treat the patient's illness, injury, or disease. Therefore, given the above, the PNS (peripheral nerve stimulation) is medically necessary.