Sprint Peripheral Nerve Stimulation System denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a SPRINT peripheral nerve stimulation (PNS) system. PNS therapy use, including the SPRINT system, is typically reserved for patients with chronic low back pain who have failed conservative pharmacologic and interventional procedures. Systematic reviews have shown mild-to-moderate pain relief, reduced opioid consumption, and improved functionality in those with chronic low back pain who have failed other conservative interventional measures. Direct studies comparing PNS SPRINT to conventional interventional methods such as epidural steroid injections, medial branch blocks, and radiofrequency ablation for lumbar spondylosis without radiculopathy and myelopathy are lacking.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for SPRINT ® Peripheral Nerve Stimulation (PNS) System. According to the guidelines from the American Society of Pain and Neuroscience, “There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation.” The authors noted that “Stimulation of occipital nerves may be offered to patients with chronic migraine headache when conservative treatments have failed. The average effect size for relief of migraine symptoms is modest to moderate (Level I, Grade B).” A systematic review found that the overall response rate of occipital nerve stimulation (ONS) was 35.7-100%, 17-100%, and 63-100% in patients with cluster headaches, chronic migraine, and occipital neuralgia, respectively.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for SPRINT peripheral nerve stimulation (PNS) system. PNS may offer greater selectivity and accuracy for cases with well-defined neuronal targets and may be effective for chronic, nociceptive pain of the shoulder and zygapophyseal joints. In general, good candidates for PNS have pain that is chronic and severe, negatively affects their functionality, and is refractory to usual medical treatments, including medications, physical therapy, and less invasive interventions such as injection therapy. Currently, only two randomized controlled trials have been performed to evaluate the utility of PNS for chronic upper extremity pain in patients.

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for a SPRINT peripheral nerve stimulation (PNS) system. In a study evaluating the use of the SPRINT system for chronic low back pain without radicular features that included 74 participants, Gilmore and colleagues noted that a majority of participants reported clinically meaningful reductions in back pain intensity after two months of percutaneous PNS treatment, with reductions in pain intensity, disability, and pain interference sustained in a majority of participants through 14 months after the start of treatment.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Sprint Peripheral Nerve Stimulation Systemwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.