Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraines.
Treatment: Pain Management; 64400 x 3 (trigeminal nerve block).
The insurer denied coverage for pain Management; 64400 x 3 (trigeminal nerve block).
The denial is upheld.

This is a patient who complains of headaches with nausea/vomiting, photophobia, phonophobia, and spots in her vision. She has the diagnoses of occipital neuralgia and chronic migraine headaches. It was reported in the office notes that the brain MRI (magnetic resonance imaging), head MRA (Magnetic Resonance Angiography), and neck imaging were unremarkable. The physical examination was unremarkable. Her medications include Imitrex and Zofran. It was reported she had failed nortriptyline, fluoxetine, propanolol, and Topamax. It was reported the treating physician is "concerned for superimposed analgesic rebound headaches." The treating physician has requested bilateral greater and lesser occipital nerve blocks.
The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

Occipital nerve blocks are performed for occipital neuralgia. Occipital neuralgia is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, back of the head, and behind the ears, usually on one side of the head. Typically, the pain of occipital neuralgia begins in the neck and then spreads upwards. Some individuals will also experience pain in the scalp, forehead, and behind the eyes. Their scalp may also be tender to the touch, and their eyes especially sensitive to light. The location of pain is related to the areas supplied by the greater and lesser occipital nerves, which run from the area where the spinal column meets the neck, up to the scalp at the back of the head. The pain is caused by irritation or injury to the nerves, which can be the result of trauma to the back of the head, pinching of the nerves by overly tight neck muscles, compression of the nerve as it leaves the spine due to osteoarthritis, or tumors or other types of lesions in the neck. The medical literature remains mixed on the efficacy of occipital nerve blocks and/or trigeminal nerve blocks for the management of occipital neuralgia/migraine headaches, in part due to small numbers of patients studied and lack of cohort studies and randomized clinical trials. They may provide temporary improvement at best. Most articles on this subject conclude that occipital nerve blocks/trigeminal nerve blocks warrant further study to determine efficacy. While occipital nerve blocks continue to be performed the medical literature does not support their use for migraines, cervicogenic headaches, and/or occipital neuralgia for diagnostic purposes or for treatment. Additional studies are necessary to determine efficacy of occipital nerve blocks as compared to conventional therapies. Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome with occipital nerve blocks/trigeminal nerve blocks. 

This service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. The medical literature remains mixed on the efficacy of occipital nerve blocks and/or trigeminal nerve blocks for the management of occipital neuralgia/migraine headaches, in part due to small numbers of patients studied and lack of cohort studies and randomized clinical trials. They may provide temporary improvement at best. Most articles on this subject conclude that occipital nerve blocks/trigeminal nerve blocks warrant further study to determine efficacy. The requested occipital nerve blocks and/or trigeminal nerve blocks are not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of Pain Management; 64400 x 3 (trigeminal nerve block) should be upheld.