Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal neuralgia
Treatment: Trigeminal Nerve Block
The insurer denied the Treatment: Trigeminal Nerve Block.
The denial is overturned. 

The patient is a female. The request is regarding a trigeminal nerve block.

Office visit note indicated that the patient was experiencing facial pain with trigeminal neuropathy. She reportedly had pain starting nine months after radiation with pain lasting one to two minutes and occurring as flashes of pain.  The pain has been present for several months at that time.  The patient has a history of trigeminal neuralgia with obstructive hydrocephalus with a history of cerebellopontine angle tumor meningioma.

Note indicates the patient presents for left trigeminal neuralgia in the context of CPA (cerebellopontine angle) tumor resection.  She has recurrence of trigeminal neuralgia in V2 (maxillary nerve)-V3 (mandibular nerve) distribution.  Precipitating pain includes talking, eating, chewing, brushing teeth, brushing hair.  She reportedly benefited from carbamazepine but experienced side effects.  She had some relief with gabapentin and pregabalin.  Physical exam reported that she had symmetric facial motion and sensation.  Tongue was in midline.  She was assessed as having severe left trigeminal neuralgia that was controlled with carbamazepine but had a side effect of hyponatremia.  They discussed alternatives to medication management, and they were going to place her on phenytoin due to side effects.

Visit indicates the patient has a history of persistent left trigeminal neuralgia, moderately controlled with carbamazepine and gabapentin.  She is experiencing mild sedation.  Pain is persisting daily, feels achy, grinding and was recommended for continued management by the provider.

Note indicated ongoing persistent pain.  She has persistent left trigeminal neuralgia and is experiencing sedation with medication and they were going to start her on lamotrigine and then discontinue carbamazepine and wean the lamotrigine, and otherwise was recommended for consideration of injection.

Note indicates the patient underwent an ultrasound-guided trigeminal nerve block via pterygopalatine fossa.

Note from nurse practitioner, indicates the patient underwent a trigeminal nerve block and reportedly experienced 80% to 95% improvement and her current visual analog pain scale was 0/10.  She reported marked reduction in the facial pain and consideration was to do it again when the procedures were available again.

Note indicated a procedure of ultrasound-guided trigeminal nerve block via pterygopalatine fossa.

Note indicates the patient reported 0/10 pain level and noted marked relief with the trigeminal nerve block.  She was assessed as having trigeminal neuralgia, trigeminal neuropathy and the plan was to repeat in 10 to 12 weeks.

Procedure indicated an ultrasound-guided trigeminal nerve block via the pterygopalatine fossa.

Note  indicated follow-up.  The patient was reported to be experiencing no facial pain.  Telemedicine visit was performed.  She reports marked pain relief with 100% post trigeminal nerve block improvement.

Note indicated ultrasound-guided trigeminal nerve block via pterygopalatine fossa.

Note indicated ongoing pain.  Level was very low.  The pain was rated at 0/10.

Yes, the health plan should cover the Trigeminal nerve block (64400x1).

The medical records detail the patient has a condition of trigeminal neuropathy with pain and neuralgia.  The patient has not had as great an improvement from medications to achieve satisfactory pain improvement.  The injections are noted to have been done previously and provide significant (near total) relief for approximately two months.  Given the patient has failed other conservative care including medications, and had positive response to injections to date, the requested injections should be covered by the health plan.

This patient's condition is relatively rare in incidence, making large controlled trials regarding treatment options unlikely to be performed.  Published data supports that when this condition is inadequately treatment with medications, or the patient experiences side effects, then consideration for injections are supported to provide periods of pain improvement.  In this case, the patient has experienced side effects with different medications or not improved with medications, and as such, injections are supported for treatment.