Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sagittal band rupture. 
Treatment: Injection (64510 x 1); peripheral nerve block. 

The insurer denied coverage for injection (64510 x 1); peripheral nerve block. 

The denial is overturned. 

According to the clinical documentation provided for review, the patient has the medical diagnosis of complex regional pain syndrome (CRPS). The patient had been seen and treated for an accident, resulting in a sagittal band rupture. The patient has a history of CRPS of the right upper extremity. The patient reported, over time, that her hand continued to swell. The patient's hand was with worsening pain. The patient had started intense physical therapy (PT) to focus on mobilization. The patient had reported increased difficulty with closing hand and making a grip. The patient also reports burning sensation, skin color changes, redness at the tip of the 2 and 3 fingers with hypersensitivity. Pain is dull, stabbing and burning. Previous treatments include physical therapy and medication. The patient had reported 100% resolution of symptoms status post (s/p) stellate ganglion block. The plan was for additional stellate ganglion block times three 1-week intervals.  Also, consideration was for ketamine infusion versus DRG (Dorsal Root Ganglion) trial. The patient had a right stellate ganglion ultrasound (US) guidance. It was noted that the patient had 80% to 90% relief from the previous stellate ganglion blocks. The patient continues with exercise on a daily basis to increase strength and mobility. The patient had a repeat stellate ganglion block. Lastly, the patient had a repeat stellate ganglion block #5. The treating provider ordered and recommended injection, 64510 x1, peripheral nerve block. The treating provider is requesting plan approval for treatment with injection, 64510 x1, peripheral nerve block. 

Given that the patient had improvement with each stellate ganglion block and continued with a home exercise program, the requested injections were considered medically necessary in this case. The patient had a diagnosis of CRPS that met the criteria. Despite prior other treatments the patient continues to have CRPS type symptoms. The patient had significant improvement with subsequent injections which would recommend repeats. 

Given the patient's history with a diagnosis of CRPS and the patient having tried and failed all other treatments including activity modification, therapy, medications, the patient continued to be symptomatic with worsening of CRPS-like symptoms. The stellate ganglion block would be the next step. Given that there is improvement with each injection and patient continues with a home exercise program, this will be the next treatment. Therefore, the request is approved and medically necessary for this patient. 

"Recent findings: Sympathetic nerve blocks (stellate ganglion and lumbar sympathetic) are the first-line interventional treatment options for patients with CRPS of the upper and lower extremities, respectively. Fluoroscopic techniques for lumbar sympathetic blocks have not significantly changed throughout the years. However, both novel fluoroscopic and ultrasound approaches to stellate ganglion blockade have arisen. In addition, novel neuromodulation therapies to treat CRPS have been developed to include new waveforms with dorsal column stimulation and entirely new nerve targets such as dorsal root ganglion stimulation. This paper will review the latest interventional treatment options available for the treatment of CRPS." (Wie, et al., 2021). 

The carrier's denial of injection (64510 x 1); peripheral nerve block should be overturned.