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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurolysis of bilateral supraorbital and supratrochlear nerves. Findings:  The physician reviewer found that  Bink and colleagues note that the results from surgical treatment of neuralgia headaches are promising, reporting that in a systematic review, total elimination  of symptoms varied between 8.3 and 83 percent. While this is a wide range, the authors noted that the number of patients with improvement of their symptoms was very high. The authors further noted that nerve decompression surgery is an effective way of treating headaches in a specific population of patients with neuralgia. Bajaj and colleagues report, A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the visual analog scale (VAS), mental health index (MHI), migraine disability assessment (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were similar in both the groups. The operative group had significant improvement in all these parameters six months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional  use of analgesics. Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients. In this case, notes reported that the patient initially presented to her provider with a long history of migraine headaches that changed approximately seven years ago to a new pain that, unlike her prior migraines, was constant and prevented her from getting out of bed for days at a time. The patient had undergone brain and cervical spine magnetic resonance imaging (MRI) and nasal septal surgery. The records noted the patient underwent neurolysis of the right and left greater occipital nerves and resection of right and left lesser and third occipital nerves with implantation into muscle, after which she patient reported significant relief in the posterior occipital region. The patient reported that currently, she had severe pain that occurred daily above her eyebrows and into the brow. The records noted that the patient had undergone four blocks of the supraorbital and supratrochlear nerves that provided very good relief, but that the pain recurred when the block wore off. The patient has disabling migraine headaches which has responded poorly to medication management and responded markedly after bilateral neurolysis of the occipital nerves. She has severe frontal migraines that respond consistently to local anesthetic injections but that return when the local anesthesia wears off. In this clinical setting, neurolysis of the supraorbital and supratrochlear nerves is appropriate based on her response to previous neurolysis and local anesthetic blocks. Therefore, neurolysis of bilateral supraorbital and supratrochlear nerves is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested neurolysis of bilateral supraorbital and supratrochlear nerves is 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 service is likely to be more beneficial for treatment 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 plastic surgery 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.