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 #3:

The patient has significant left trigeminal neuropathic pain. The patient failed best medical management. The patient has failed other treatment options, including medication. The notes also stated the patient has occipital neuralgia as well as trigeminal neuropathic pain. The recommendation is trial percutaneous, trigeminal, and occipital nerve stimulation. The patient has had a psychiatric evaluation and was cleared for surgery at that time. Notes indicate the patient has attempted two previous occipital nerve blocks with temporary relief.

All available medical documentation was reviewed.

The literature does support the use of occipital nerve stimulators (ONS), and this is well accepted within the Neurosurgery community.

With the evidence available, the response to ONS was sustained in the majority of patients with cluster headache with low rates of loss of efficacy in this patient population (Montenegro MM, Kissoon NR., 2023).

Occipital nerve stimulation appears to offer a safe and efficacious treatment for refractory short-lasting unilateral neuralgiform headache attacks with significant improvements sustained in the long term. The procedure has a low adverse event rate when conducted in highly specialized units (Miller S, Watkins L, Matharu M., 2018).

With regards to trigeminal neuralgia (TN), this patient has failed best medical management and there are smaller studies that support its use. This is a debilitating disease and this is the most appropriate management option in this setting. 

These results suggest that ONS can induce an improvement in TN recurring after several surgical treatments, and the benefit of the stimulation can be sustained in the long term (Balossier A, Donnet A, Regis J, Leplus A, Lanteri-Minet M, Fontaine D.,  2022).      

This is Food and Drug Administration (FDA) approved and has been a validated device by all regulatory bodies involved.

This patient is a good candidate for this device and treatment. There are limited options available for them and this is the most appropriate and reasonable option at this time. This patient has failed all medical options that are first line, and this is the most appropriate next step for this patient with severe pain. A trial is the most appropriate method to proceeded and that is what is being recommended.     

This is the most appropriate and next best option for this patient. They have attempted all medical therapies to date, and there are limited options available for them at this time.     

The adverse risks are minimal compared with continued debility from these issues. The benefits far outweigh the risks for this patient and therefore this should be approved.      

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.