Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myofascial pain
Treatment: Dorsal root ganglion stimulation (DRG) to treat myofascial pain
The insurer denied the dorsal root ganglion stimulation (DRG) to treat myofascial pain. The denial is overturned. 

The patient is a female with history of left lower extremity pain secondary to complex regional pain syndrome and sympathetic mediated pain with prior diagnostic left lumbar sympathetic blocks done twice with 30% improvement in pain along with improved functionality. She completed the preoperative neuropsychological evaluation with recommendation for her to proceed with the dorsal root ganglion stimulation. 

Her main symptoms are pain, hyperesthesia and allodynia based on complaint of hypersensitivity to touch associated with pain with swelling and no other sudomotor changes.

Previously, she failed several conservative measures including physical therapy, several injections, Gabapentin, Ibuprofen, Naproxen, Flexeril, Meloxicam, etc.

The request is for a trial of percutaneous dorsal root ganglion stimulation. 

Yes, the health plan should cover the proposed treatment. 

The proposed dorsal root ganglion stimulation is medically appropriate as she has exhausted all conservative measures and she has also met national standard criteria including indication of complex regional pain syndrome/sympathetic mediated pain syndrome based on symptoms/signs and diagnostic sympathetic blocks, failed conservative measures as stated in clinical summary, and also recommendation to proceed with the dorsal root ganglion stimulation trial after neuropsychological evaluation.

The medical appropriateness of dorsal root ganglion stimulation is stated by Conrad Harrison, et al that there is now Class A RCT (randomized clinical trial) evidence that dorsal root ganglion stimulation provides superior pain relief to SCS (spinal cord stimulation) for complex regional pain syndrome and causalgia of the lower limb, while Michael Esposito, et al stated that there are several advantages to target the dorsal root ganglion, including lower energy usage, more focused and posture independent stimulation, reduced paresthesia, and improved clinical outcomes. The procedure is now mainstream and indicated for complex regional pain syndrome and it is not experimental or investigational.

She failed subsequent conservative management measures including physical therapy, several injections, Gabapentin, Ibuprofen, Naproxen, Flexeril, Meloxicam, etc. In addition, she had a neuropsychological assessment that concluded that she is a good candidate for the SCS (spinal cord stimulation) trial.

Yes, the requested dorsal root ganglion stimulation is likely to be more beneficial than any other standard treatment for complex regional pain syndrome in this instance and therefore medically appropriate, and withholding the procedure in whole or in part is reasonably likely expected to affect the patient's health as all other options for the treatment of chronic neuropathic pain including complex regional pain syndrome have been documented to have been exhausted. The patient has failed all conservative measures and has been ruled to be a good candidate for the dorsal root ganglion stimulation trial by virtue of the neuropsychological evaluation.