Is a cervical spinal cord stimulator (SCS) trial medically indicated for an 18-year-old patient with a history of C7-T1 brachial plexus injury due to an accident?

Cervical SCS Trial is NOT Medically Indicated for This Patient

Based on the insurance criteria provided and the absence of CRPS diagnosis, this cervical spinal cord stimulator trial does NOT meet medical necessity criteria and should be denied. The patient's diagnosis of brachial plexus injury with neuropathic pain does not align with the established coverage policy, which explicitly states cervical SCS is "unproven for any indication other than CRPS."

Determination: DENIAL

Rationale Based on Coverage Criteria

Primary Issue: Indication Not Met

• The insurance policy explicitly excludes cervical SCS for all indications except CRPS 1
• The patient has no documented diagnosis of CRPS in the clinical record
• The documented diagnosis is "Neuralgia and neuritis, unspecified" secondary to C7-T1 brachial plexus injury with root avulsion
• The coverage criteria state: "The use of cervical dorsal column stimulation for the treatment of members with cervical trauma...or any other indication (other than CRPS) - NOT MET - no dx CRPS listed"

Clinical Context vs. Policy Limitations

While the clinical scenario presents a challenging pain management case, the determination must be based on the stated coverage policy:

Patient Presentation:

• 18-year-old male with traumatic lower trunk (C7-T1) brachial plexus injury [@case details@]
• MRI-confirmed T1-T2 root avulsion with pseudomeningocele [@case details@]
• Severe neuropathic pain (NAS 2 at rest, constant sharp/burning/shooting pain) [@case details@]
• Failed conservative management including pregabalin, nortriptyline, nerve transfer surgery, and physical therapy [@case details@]
• Psychological evaluation cleared for neuromodulation [@case details@]

Evidence Supporting SCS for Brachial Plexus Injury:

• Cervical SCS has demonstrated effectiveness for neuropathic upper limb pain with average pain reduction from NAS 6.8 to 2.8 2
• A multicenter registry showed 60-67% pain relief at 6-12 months post-cervical SCS implantation 3
• Real-world outcomes demonstrate sustained pain relief with 50.3% of patients achieving NAS ≤3 4
• Recent consensus guidelines support SCS trial for neuropathic pain conditions 5

However, the coverage policy supersedes clinical evidence when the specific indication is explicitly excluded.

Coverage Criteria Analysis

Criteria NOT Met:

1. Primary diagnosis requirement: CRPS is the only approved indication for cervical SCS per the stated policy
2. Diagnosis on record: Neuralgia and neuritis, unspecified (not CRPS)
3. Policy exclusion: Explicitly lists "cervical trauma" as an unproven indication

Clinical Considerations (Not Sufficient to Override Policy):

• The patient has exhausted appropriate conservative treatments over 7 months [@case details@]
• Psychological screening shows no contraindications [@case details@]
• The treating physician appropriately discussed both SCS and PNS options [@case details@]
• Evidence exists for SCS efficacy in similar neuropathic conditions 2, 3, 4

Alternative Recommendations

Within Policy Constraints:

1. Peripheral Nerve Stimulation (PNS): The treating physician mentioned PNS as an alternative that "can be effective in this setting" for brachial plexus injury [@case details@]. If the policy does not explicitly exclude PNS for this indication, this may be a viable alternative to explore.

2. Pain Management Optimization:

   • Trial of alternative neuropathic pain medications (gabapentin, duloxetine, topical agents) 1
   • Consider interventional pain procedures that may be covered (nerve blocks, radiofrequency ablation if anatomically appropriate)
   • Intensive physical therapy/occupational therapy programs [@case details@]

3. Policy Exception Request: The treating physician could submit a formal appeal with peer-reviewed literature demonstrating efficacy of cervical SCS for traumatic brachial plexus injury 2, 3, 4, though success is uncertain given the explicit policy language.

Important Caveats

• This denial is based solely on the stated coverage criteria, not on clinical appropriateness or evidence-based medicine
• The clinical evidence supports cervical SCS as potentially beneficial for this patient's condition 2, 3, 4
• The ESMO-EONS-EANO guidelines note that SCS "may be discussed for selected patients with truly refractory neuropathic pain" when conservative approaches fail 1
• The patient's young age (18 years) and significant functional impairment make this a particularly challenging case where neuromodulation could meaningfully impact quality of life

The determination must align with the coverage policy as written: cervical SCS is considered unproven for all indications except CRPS, and CRPS is not documented in this patient's clinical record.