Having discussed the new and interesting procedures being used or studied by neurosurgeons, it is time to throw a wet blanket on some of that. Evidence-based-medicine (EBM) is valuable and a stringent measure of what is effective, what is safe, and what is not. Insurance companies determine whether or not they will approve of or pay for procedures largely based on the evidence available. When there are large, carefully done studies—and especially a lot of them—regarding a treatment, EBM is a valid determinate of whether or not a doctor and/or a patient should chose the well-studied procedure or not. Let me add parenthetically that EBM is far more accurate than TV advertising or your aunt Minnie’s anecdotal experience. However, EBM has a limitation. Procedures that are well established but not recently studied; studies that have only small numbers of patients because only a few surgeons know how to do the operation; and studies that have only small numbers of patients because the disease condition is infrequent or rare, may not have and may never have sufficient data to rank them as EBM verified as effective and safe.
That having been said, I submit to you Aetna Insurance Company’s considerations—taken from their website and contributions to discussions on effectiveness of procedures discussed elsewhere. Aetna considers a wide-range of procedures to be “experimental and investigational” and therefore their effectiveness has not been established and will not be covered by insurance. This may prove difficult for the patient. The following are examples of procedures so designated:
FOR CERVICOGENIC HEADACHE: Botulinum toxin (However, for chronic migraine, is medically necessary for chronic migraine); cryo (freezing)-denervation, decompressive neck surgery, electrical stimulation, ganglionectomy, local injections of anesthetics or corticosteroids, and radiofrequency denervation for cervical facet pain.
FOR OCCIPITAL NEURALGIA: cervical rhizotomy, cryo-denervation, dorsal column stimulation, electrical stimulation of the occipital nerve, ganglionectomy, neurectomy, neurolysis of the great occipital nerve with or without section of the inferior oblique muscle, occipital nerve block, and surgical release of the lesser occipital nerve within the trapezius muscle and other procedures to decompress the occipital nerve.
FOR CLUSTER HEADACHE: Ablation or electrical stimulation of the sphenopalatine ganglion, bariatric surgery, decompression of the greater occipital nerve, supra-orbital nerve, and supratrochlear nerves, DBS, occipital nerve stimulation, nerve decompression, suboccipital nerve stimulation, and supraorbital nerve stimulation.
That pretty much covers what is available for treating several very troublesome conditions. What treatment is offered, discussed, or undertaken is a matter between the doctor and the patient. It is obligatory for the doctor to be informed, frank, and honest. It is necessary for the patient to learn about what is being proposed, to weigh the evidence—including the doctor’s experience, as opposed to relying solely on what insurance companies regard as EBM or on anecdotes. Patients need to be far more sophisticated and educated than they were before. Doctors need to keep better records of their own results and to continue to learn: the motto must be that continuing medical education is crucial; so, study, study, study.
