Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal Neuralgia. 
Treatment: Injections to block or destroy a certain nerve for pain (peripheral nerve block). 

The insurer denied injections to block or destroy a certain nerve for pain (peripheral nerve block). 
The determination is overturned. 

The patient has a diagnosis of trigeminal neuralgia. Treatments tried include medications from multiple classes and trigeminal nerve blocks. The present medication regimen provides inadequate pain relief. A previous medication caused hyponatremia. Trigeminal nerve blocks provide substantial improvements in pain and are well tolerated. At issue is whether the proposed health service or treatment, injections to block or destroy a certain nerve for pain (peripheral nerve block), likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed trigeminal nerve block is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

A prospective case series of ultrasound guide trigeminal nerve block via the pterygopalatine fossa for treatment of trigeminal neuralgia concludes "the use of ultrasound guidance for injectate delivery in the pterygopalatine fossa is a simple, free of radiation or magnetization, safe, and effective percutaneous procedure that provides sustained pain relief in trigeminal neuralgia or atypical facial pain patients who have failed previous medical interventions" [1]. 

A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia (TN) states (in part) "Of 431 studies, 17 studies were identified that reported immediate results of acute treatment in TN. The evidence suggests that the following interventions may be beneficial: local anaesthetic, mainly lidocaine (ophthalmic, nasal or oral mucosa, trigger point injection, intravenous (IV) infusion, nerve block); anticonvulsant, phenytoin or fosphenytoin (i.v. infusion); serotonin agonist, sumatriptan (s.c. injection, nasal). Other referenced interventions with very limited evidence include N-methyl-d-aspartate receptor antagonist (magnesium sulphate infusion) and botulinum toxin (trigger point injection). 

A retrospective case series of urgent care peripheral nerve blocks for refractory trigeminal neuralgia concludes "The treatment paradigm for trigeminal neuralgia (TGN) remains unclear when a patient fails conservative medical therapy. In this case series, many patients achieved rapid and sustained TGN pain relief with peripheral trigeminal nerve blocks. This modality should be considered as a potential therapeutic option in the emergency department (ED) or urgent care setting" [3]. 

In this case, the patient's medical regimen provides inadequate pain relief and trigeminal nerve blocks provide substantial improvements in pain. Other treatment options for the management of trigeminal neuralgia such as microvascular decompression and/or gamma knife radiosurgery entail greater risk than nerve blocks. 

Based on the clinical material submitted and peer review medical literature, the trigeminal nerve block is considered likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.