Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right-sided facial pain

Treatment: Pain management outpatient procedure (64400 x 1); nerve block injections

The insurer denied coverage for pain management outpatient procedure (64400 x 1); nerve block injections.

The denial is upheld. 

This is a male patient with a long history of right-sided facial pain, low back pain and sleep apnea. The patient previously had relief of facial nerve pain from a trigeminal nerve block and was also on Gabapentin. He was stable on this medication but developed coronavirus disease 2019 (COVID-19); the Gabapentin was discontinued during his hospitalization and the pain returned. The request is for a right trigeminal nerve block with steroid injection (64400 x 1). The patient tried and failed several anticonvulsants. 

Obermann (1) reviewed the management of Trigeminal Neuralgia (TN) and concluded: "Although many patients respond to first-line therapy initially, most treatment approaches tend to lose efficacy over time, so new and innovative treatment options are warranted. Many patients will receive surgery after their medical treatment failed, whereas others require medical treatment after the long-term efficacy of surgery slowly deteriorates. Medical therapy should be the first choice, and only after two failed treatment attempts may surgical interventions be considered in patients. Between 33 and 50% of patients may require surgical intervention at some point. No direct comparison studies between medical and surgical treatment exist. Medical treatment-refractory patients with a minimum of two adequately dosed recommended TN medications, including carbamazepine (CBZ), are candidates for surgical treatment. The patients' symptoms, not any neuroimaging investigations, are the most relevant factor for this decision. TN surgical management is either ablative (destructive) with the intentional destruction of sensory function of the trigeminal nerve or non-destructive with mere decompression of the trigeminal nerve and preservation of its normal function."

Similarly, recent practice guidelines (2) do not include local anesthetic with steroid. "It is recommended that patients should be offered surgery if pain is not sufficiently controlled medically or if medical treatment is poorly tolerated. Microvascular decompression is recommended as first-line surgery in patients with classical TN. No recommendation can be given for choice between any neuroablative treatments or between them and microvascular decompression in patients with idiopathic TN. Neuroablative treatments should be the preferred choice if magnetic resonance imaging (MRI) does not demonstrate any neurovascular contact. Treatment for patients with secondary TN should in general follow the same principles as for primary TN. In addition to medical and surgical management, it is recommended that patients are offered psychological and nursing support."

Local anesthetic with steroid injection is not among the recommended therapies. While trigeminal block may have a role in diagnosis, ongoing blocks are not evidence based. The requested procedure is not medically reasonable or necessary.

The health care plan acted reasonably, with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for pain management outpatient procedure (64400 x 1); nerve block injections is upheld. Medical necessity is not substantiated.