The patient with history of tobacco use presents with headache and chronic neck and right arm pain. The patient has had four cervical surgeries in the past including 3 anterior with fusion and 1 posterior surgery. Patient uses hydrocodone-acetaminophen 10-325 four times a day (qid) as needed (prn) and Cyclobenzaprine 5 milligrams (mg) three times a day (tid) prn. The patient has undergone a trial of physical therapy, chiropractic care, occipital nerve block and cervical injection therapy with no relief of symptoms. Request has been made for occipital nerve stimulator placement. The health plan's determination is upheld.

The patient has a very complex history of cervical surgery with multiple co-morbidities. The etiology of patient's symptoms including headaches are most likely multifactorial. The patient presents with headaches and neck and arm pain and does not represent the typical occipital neuralgia patient. Occipital nerve stimulator and generator placement has been used for intractable occipital neuralgia but systematic review of the literature by the Congress of Neurological Surgeons at best concluded it to be a level III recommendation. The procedure is an option for a select group of patients with intractable occipital neuralgia but would be considered experimental and investigational particularly in this patient. Review of the literature does not support the requested procedure.