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

Nature of Statutory Criteria/Case Summary: A review of the records indicates that on 12/3/18, the patient presented to her provider for follow-up regarding ongoing migraines.  Findings:  The physician reviewer found that this patient rated her pain as 10 on a scale of 10 at worst, and an 8 of 10 at present. Previous treatments included medication therapy, physical therapy, epidural blocks, and Botox injections. Nerve block injections were administered to the left side. On 12/5/18, the patient reported that her pain decreased from 8 of 10 to 2-3 of 10 following the nerve block injections. Injections were then repeated. She reported that her pain decreased from 8 of 10 to 1-6 of 10. The Health Plan indicates that the injection at issue was not likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. Therefore, the Health Plan has denied coverage for the treatment at issue.Findings:  One physician reviewer found that Greater occipital nerve blocks (GONBs) have not been medically proven to be an effective treatment of headache disorders or occipital neuralgia. According to the current expert consensus of the American Headache Society (AHS), the use of peripheral nerve blocks in headache disorders is not recommended. The authors concluded that with the exception of cluster headache, there is a paucity of evidence supporting a role for GONBs in headache treatment (Blumenfeld, et al). A randomized controlled trial of occipital nerve blocks for migraine headaches was completed by Dilli and colleagues. Therefore, the injection of the occipital nerve (CPT-66405) at issue was not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Two physician reviewers found that the patient has been diagnosed with occipital neuralgia by physical examination. Another key element to the diagnosis is a positive response to occipital nerve blocks which is the treatment due to its ability to relieve pain and act as a diagnostic marker. Considering the information reported by the provider, the patient has several neurological conditions, including occipital neuralgia. The occipital nerve blocks served as a diagnostic aid and provided therapeutic relief. According to the current data, guidelines, and recommendations, the injection of the occipital nerve (CPT-66405) at issue was likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Headaches secondary to greater occipital neuralgia can be worsened secondary to myofascial neck pain. GON block intervention can significantly alleviate pain, reduce the number of headaches per day, and decrease medication consumption (Zhang, et al). There are adequate data in the peer-reviewed medical literature demonstrating the benefits of GON blocks in this clinical setting (Tang, et al). Therefore, the injection of the occipital nerve (CPT-66405) at issue was likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.Final Result: Two out of three reviewers determined that the requested occipital nerve (CPT-66405) injection was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology and are 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.