Diagnosis: Postherpetic neuralgia.
Treatment: Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).

The insurer denied the Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).
The denial is overturned.

The patient is a male. As noted the patient complains of persistent intractable post herpetic neuralgia. He reports having an 8/10 level of pain for the past week. The patient has failed best medical management to date. His pain is severe, intractable, and interfering with his quality of life and activities of daily living. Continued severe pain in the face as a result of post herpetic neuralgia can become debilitating and further reduce activities of daily living with associated depression.

Yes, the Health Plan should cover the requested health service.

The prior final adverse determination denial notice denied the request noting that it was requesting approval for occipital nerve stimulation. It stated that the role of this procedure remains uncertain and that the available evidence has not proven that it is useful to improve help outcomes.

This reviewer disagrees with this determination. The request is for Peripheral nerve field stimulation in a patient with medically refractory trigeminal neuralgia. This treatment does involve a modified variant of stimulation. There is, additionally, peer-reviewed literature that supports this efficacy in the treatment of refractory trigeminal neuralgia. Specifically, the studies suggest a possibly beneficial long-term effect of PNFS (peripheral nerve field stimulation) on refractory trigeminal neuralgia.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

As noted the patient complains of persistent intractable post herpetic neuralgia. He reports having an 8/10 level of pain for the past week. The patient has failed best medical management to date. There are no other standard therapies to offer this patient at this point.