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

  The enrollee requested reimbursement, and authorization and coverage, for an occipital Nerve Block (CPT codes 64405-50 and 64450-50). The enrollee has a history of occipital neuralgia and intractable migraine. He has experienced more than six months of disabling chronic pain; refractory to multiple classes of medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), opiates, anti-epileptics, antidepressants, muscle relaxants, physical therapy, massage, acupuncture and other conservative treatments. The enrollee underwent bilateral greater and lesser occipital nerve block to reduce pain and restore function. The enrollee notes his pain has become less severe and less frequent after the occipital nerve block. His provider specializes in treating migraines and has noted occipital nerve block is as effective as interventional treatment strategies for conditions such as this enrollees. The provider notes occipital nerve block is an established procedure that is utilized by the best hospitals in the state. The enrollee has occipital neuralgia and intractable migraine. He had tried and failed nonsteroidal anti-inflammatory drugs (NSAIDs), opiates, anti-epileptics, antidepressants, muscle relaxants, physical therapy, massage, and acupuncture. Occipital nerve block can be helpful to those who may not respond to other treatments. This procedure has been proven beneficial in treating individuals with various forms of headaches. It is widely used by neurologists to treat such conditions. The physician reviewer found that migraine headaches comprise a significant proportion of emergency department visits. There are multiple pharmacologic treatment modalities for migraine abortive therapy, but these treatments rarely target the precise area of pain and thus elicit multiple systemic effects. Anesthesia pain literature describes how occipital nerve blocks can provide immediate pain relief from occipital migraines and can produce long-term resolution of occipital migraines. Literature describes how occipital nerve blocks (ONB) are technically simple procedures which successfully provide dramatic pain relief results. They are also a relatively safe and beneficial alternative to other headache treatment options. Research has demonstrated ONBs can be performed safely in outpatient settings. A meta-analysis of six randomized controlled trials (RCTs) assessing the efficacy of greater occipital nerve (GON) block versus placebo in migraine enrollees showed GON block intervention significantly reduced pain scores, number of headache days, and medication consumption. Occipital nerve blocks are typically utilized for the treatment of medically refractory occipital neuralgia.  The condition is diagnosed by the reproduction of headaches on palpation of the occipital nerve.  The enrollee had recurrent findings of occipital neuralgia on examination and he was refractory to other treatments.  Treatment for occipital neuralgia typically includes conservative management; including medications, applications of heat and cold and occipital nerve blocks. After occipital nerve blocks are performed and the pain returns, recommendations are for the individual to proceed with repeat blocks. The documentation noted this enrollee had a reproducible Tinel's on exam.  The enrollee has suffered from symptoms for greater than six months.  Therefore, it does appear the requested occipital nerve block would be considered standard of care in this case and would be more beneficial than any other standard treatment.     Final Result: Three of the three reviewers determined that the requested services were, and are, likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology and are actively practicing.  All three 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.