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. 

This woman has a history of an accident while pulling a rubber cord, causing 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 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. 	

Clinical practice guidelines (1) support the performance of Stellate ganglion blocks in coordination with Physical therapy: 

"There is some evidence for the efficacy of the classic Stellate Ganglion Block and Lumbar Sympathetic Block [SGB or LSB] in an apparent subset of subjects (level 3) as above. Apart from possible efficacy as an intervention, a secondary reason these blocks remain in most CRPS (complex regional pain syndrome) treatment algorithms is the clinical differentiation of Sympathetically Maintained Pain from Sympathetic Independent Pain and, thus, to provide a rationale for a course of sympathetic blockade and perhaps (controversially) neuro-ablation in this subset of CRPS patients with SMP (sympathetically maintained pain). The empirical utility of the SGB or LSB when used in a short series in conjunction with active reanimation physiotherapy is advocated based on consensus recommendations (level 4)" Samen et al (2) found "A weak correlation was found between immediate-term pain relief and the extent of temperature rise for the cohort (R(thermal resistance) =0.192, P (probability)=0.043). Greater immediate-term pain reduction was reported among patients who experienced a temperature increase >=7.5C (Celsius) (mean 4.1; 95% confidence interval [CI]: 3.33 to 4.76) than among those who experienced a temperature increase <2C (2.3; 95% CI: 1.36 to 3.31) or >=2C to <7.5C (2.9; 95% CI: 1.8 to 3.9; P=0.036). The correlations between temperature increase and intermediate-term pain score reduction at 4-8 weeks (R=0.052, P=0.329) and between immediate- and intermediate-term pain relief (R=0.139, P=0.119) were not statistically significant. 

They concluded: 
"A weak correlation was found for those who experienced greater temperature increases after the block to also experience greater immediate pain relief. Higher temperature increase cutoffs than are typically used might be necessary to determine whether a patient with complex regional pain syndrome has sympathetically maintained pain." 

This conclusion supports the needs for stellate Ganglion nerve blocks that may need to be repeated to produce a significant increase in hand temperature. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

Evaluate whether injection (64510 x 1); peripheral nerve block is considered more beneficial for this patient's diagnosis, addressing the following in your discussion: 

The scientific evidence in peer-reviewed literature does support the result of improvement in health outcome. 

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

The injection (64510 x 1); peripheral nerve block is the best available treatment for this patient at this time. 

The adverse risks do not increase over standard treatment/services. This procedure is considered more beneficial than any other standard services. 

The carrier's denial of injection (64510 x 1); peripheral nerve block should be overturned.