Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for guided cervical occipital injections. Current clinical evidence does not support the use of CT-guided occipital nerve block injections over standard therapy for the treatment of occipital neuralgia and cervicogenic headaches. Barmherzig and Kingston report that while anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief, further studies are required to consolidate efficacy regarding the comprehensive management of occipital neuralgia and cervicogenic headaches. The authors did not report that occipital nerve blocks were superior to standard therapy options for this condition. Urits and colleagues note, Historically, conservative treatments such as medications and alternative therapies are first line; however, many patients fail conservative management and experience refractory symptoms. Local injections with corticosteroids provide pain relief but are only temporarily effective, leading to frequent injections. As a result, treatment of occipital neuralgia is a challenging matter, and novel therapies are necessary to improve outcomes. The authors further note that injections could be used as a transitional treatment bridge for patients who would benefit from more invasive neuromodulation techniques, but do not note specifically that occipital nerve injections are superior to standard therapy. In this case, the patient has a diagnosis of  occipital neuralgia  and a history of chronic daily headaches and migraine headaches. Progress notes dated 11/6/20 reported that the patient had previously responded to greater occipital nerve blocks in May and September 2020, but that the benefits were subsiding. The patient was treated with a first round of Botox therapy for chronic migraine headaches. In progress notes dated 1/13/21, the patient reported response to Botox injections, and was referred for evaluation on the possibility of image-guided greater occipital nerve blocks. While the records show multiple repeat injections, the benefits of the injections appear to last only for a few months, and the records do not document plans for a more definitive treatment beyond repeated occipital nerve injections. In this clinical setting, current medical literature does not endorse the use of occipital nerve blocks as a method of durable pain relief. Therefore, CT-guided cervical occipital injections are not likely to be more beneficial for the patient than any available standard therapy.Findings:  Two of the three physician reviewers found the requested guided cervical occipital injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 are is board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain management and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.