Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left occipital neuralgia
Treatment: decompression, unspecified nerve(s), code 64722
The insurer denied coverage for decompression, unspecified nerve(s), code 64722.
The denial is upheld. 

The patient is a young female adult. Magnetic resonance imaging (MRI) of the brain showed findings related to prior posterior surgical decompression for Chiari malformation. Magnetic resonance imaging (MRI) of the cervical spine showed the interval performance of a suboccipital craniectomy and resection of the posterior arch of cervical one (C1) to relieve a Chiari I malformation. 

There was diagnosis of left occipital neuralgia, and a physician performed an occipital nerve block. 

The patient was seen by her physician for evaluation and treatment of left occipital neuralgia. He noted that the patient had a prior Chiari malformation in the past with subsequent severe headache pain in the left occipital region. He noted that the patient had difficulty attending school due to the pain. He noted that the patient had immediate and short-lived relief following occipital nerve blocks. He noted that the patient failed gabapentin due to gastrointestinal (GI) side effects. On exam, he noted that the patient had tenderness at the site of the pain. He noted that the procedure for occipital nerve exploration and obliteration was discussed.

He noted that the patient suffered from chronic daily occipital headaches following the Chiari surgical decompression, that the patient had tenderness along the course of the left occipital nerve, that the plan was to consider occipital nerve block and Botox injection, that the plan was to obtain MRI (Magnetic resonance imaging) of the brain and cervical spine, and that the plan was to give a trial of gabapentin. 

He noted that the patient had no relief with gabapentin and that it caused gastrointestinal (GI) side effects, that the patient's diagnosis was most likely post-surgical inflammation or decompression injury of the left occipital nerve, and that an occipital nerve block was performed. 

The patient reported immediate relief of her headache following the occipital nerve block done on the prior visit, that the effect lasted for three days, and that a repeat occipital nerve block was performed during the visit. 

Other non-invasive options should be explored like Botox injection and pulsed radiofrequency, prior to proceeding with invasive surgical decompression. Decompression, unspecified nerve(s), code 64722 is not considered medically necessary for this patient. 

"Occipital neuralgia (ON) is a painful condition affecting the posterior head in the distributions of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. It is paroxysmal, lasting from seconds to minutes, and can cause lancinating pain. It is paramount that interprofessional team members recognize the specific diagnostic criteria for this condition and the differential diagnosis. There are multiple treatment modalities available, several of which have well-established efficacy in treating this condition... as referenced.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for decompression, unspecified nerve(s), code 64722 services is not substantiated.