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. Pulling a rubber cord, caused immediate swelling, and severe pain in her right hand. The next day, the patient saw a hand specialist, where she was diagnosed with a sagittal band rupture. After failing conservative treatment measures, the patient visited another doctor, where she was treated 5 days per week for 4 weeks with physical therapy (PT) and lymph drainage twice a week. When the patient returned, a pain specialist performed 5 stellate ganglion block injections, one to two weeks apart with significant improvement in hand function. A televisit notes the patient as assessed to have complex regional pain syndrome (CRPS) of the right upper limb. The doctor advised the patient to start the nerve block injections as early as possible. 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. 

The provider who has evaluated and treated the patient with failed conservative therapy is the regulatory body who should have final approval to order and proceed with the procedure for the diagnosis of complex regional pain syndrome upper extremity. 

This patient is a good candidate for injection (64510 x 1); peripheral nerve block. 

Injection, 64510 x 1, peripheral nerve block is the best available treatment for this patient at this time. 

In light of failed conservative therapy, (64510 x 1); peripheral nerve block is the best available treatment for this patient at this time. 

The adverse risks are not increased over standard treatment/services. 

Peer Reviewed literature demonstrates that (64510 x 1); peripheral nerve block is both safe and efficacious for the diagnosis of complex regional pain syndrome. 

"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). 

"Conclusion: Our study showed a wide variation in current practice among pain physicians in treating CRPS with SBs (Sympathetic blocks). There is a clear need for evidence-based guidelines on when and how to perform SBs for CRPS." (Zhu, et al., 2019). 

"Conclusions: Data indicate that us-SGBs (Stellate Ganglion Block) are safe and effective in reducing sympathetically maintained pain in patients with CRPS and neuropathic pain syndromes. Pain reduction after the first blockade may predict total pain reduction after a blockade series. Other clinical measures seem unsuitable to predict effectiveness." (Aleanakian, et al., 2021).     
    
The carrier's denial of injection (64510 x 1); peripheral nerve block should be overturned.