Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve decompression surgery (CPT 64716 x 17  neuroplasty and transposition of cranial sensory nerve; CPT 21899  insertion of pain control catheter  neck; with approved CPT 64771 x 2  ablation of cranial sensory nerve; and CPT 64999  partial resection of semispinalis capitis muscle). Findings:  The physician reviewer found that a number of medications, including non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and antiepileptic medications have been tried with variable relief in the treatment of patients with occipital neuralgia. Injection therapies, including combinations of anesthetics and steroids, and Botox have become a standard treatment strategy with demonstrated efficacy. Grigsby and colleagues recently performed a prospective cohort study on 26 patients with occipital neuralgia. The authors reported that two-thirds of patients experienced meaningful improvement and 70% lasted more than 30 days with cryoablation. This patients condition is consistent with a classic complex headache condition. She has reportedly failed multiple medical strategies as documented extensively in her records. Several of her providers have suggested occipital neuralgia as a diagnostic entity for her headache syndrome. There is documented evidence that the patient achieved some transient relief from one of her diagnostic blocks. For these reasons, the occipital nerve decompression surgery (CPT 64716 x 17  neuroplasty and transposition of cranial sensory nerve; CPT 21899  insertion of pain control catheter  neck; with approved CPT 64771 x 2  ablation of cranial sensory nerve; and CPT 64999  partial resection of semispinalis capitis muscle) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Three of the three physician reviewers found the occipital nerve decompression surgery (CPT 64716 x 17  neuroplasty and transposition of cranial sensory nerve; CPT 21899  insertion of pain control catheter  neck; with approved CPT 64771 x 2  ablation of cranial sensory nerve; and CPT 64999  partial resection of semispinalis capitis muscle) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in neurological surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.