Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Surgical Services

The insurer denied the nerve decompression. The denial is upheld.

The patient is a female who underwent a right occipital nerve decompressio for cervico-occipital neuralgia. In 2017 she underwent an occipital block and ablation of the right inferior occipital lobe. She had an anterior discectomy and fusion C3-4 through C7 with posterior fusion across C6-7. She also had a prior right sided craniotomy due to right anterior temporal lobe arteriovenous malformations (AVM) resection. Neurosurgery notes were reviewed. She was seen for a telemedicine visit. She was suffering immensely due to her occipital region pain and had failed best medical management. Her pain was severe, intractable and interfered with her quality of life and activities of daily living. Notes indicated that she was pain free in the region where the particular occipital nerve branches were decompressed. She would benefit from further exploration and decompression. Earlier notes from 2018 were reviewed and occipital stimulation was recommended. Her pain was persistent in the right scalp region and her other pain significantly improved with decompression of her occipital and zygomaticotemporal nerve. She had a history of multiple spine operations with severe intractable occipital region pain. Her medications included Morphine, Zanaflex, Zofran, gabapentin, Zoloft, Toprol, Mobic and Tegretol. Her last noted exam showed a positive Tinel's sign over the right occipital region and right temporal region.

The patient has had a prior occipital nerve decompression with positive results. She continues to have pain in the region and her surgeon stated that she would benefit from further exploration and decompression. She recently had a trigger point injection to the occipital area that was beneficial. It appears her last exam that showed a positive Tinel's in the occipital area was in 2017 and there has been no neurological exam since by the surgeon. Her exams by Neurology are normal. The appeal and office notes are not specific as to where there is compression of the nerve, and if there has been any other imaging done to show a compression. Therefore, there is not sufficient evidence that the decompression would likely be more beneficial than any standard treatment or treatments.

The American Association of Neurological Surgeons (AANS) does not list occipital nerve decompression as a treatment for occipital neuralgia but lists occipital nerve stimulation, spinal cord stimulation and C 2,3 Ganglionectomy for treatment of the condition.