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

Physician 1:  The patient is a 30-year-old female with a history of occipital neuralgia and she is status post right parietal bone osteoma removal in 1996. The patient has been under the care of a pain management specialist and has been treated with medications and multiple occipital nerve blocks. Her provider recommended the patient undergo a radiofrequency thermal coagulation procedure and submitted a request for authorization to the Health Plan. The Health Plan denied the request citing the experimental nature of the procedure.The medical literature does not strongly support the application of radiofrequency thermal coagulation for the treatment of occipital neuralgia and the record provided for review does not demonstrate the enrollee has exhausted conservative treatment modalities. Various therapies such as a TENS unit, acupuncture, physical therapy, biofeedback training and medications including antidepressants, antiepileptics and muscle relaxants have been shown to be beneficial in the treatment of occipital neuralgia. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 30-year-old female status post osteoma excision from the right parietal bone that has been diagnosed with occipital neuralgia. She has been treated with various medications and monthly occipital nerve blocks, but reports persistent pain. Her pain management specialist recommends a radiofrequency thermal coagulation procedure. The Health Plan considers the procedure experimental/investigational, and has therefore denied authorization.Occipital neuralgia is a condition which involves frequent and severe headaches characterized by paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The treatment plan depends upon the severity, character and location of the pain as well as the patients age, ongoing medical conditions, and ability to tolerate other medical interventions. Standard therapies include medications to relieve pain and muscle spasms, localized injections, physical therapy and massage, and should be fully explored. Although pulsed radiofrequency treatment of the occipital nerves in refractory cases has shown some promising results, irreversible neuroablative therapies have not been sufficiently studied and their safety and efficacy remain unproven at present. As such, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 30-year-old female with occipital neuralgia. She underwent surgical removal of a parietal osteoma in 1996. The patient indicates that the conservative therapies tried thus far have not been effective for the treatment her pain. Her provider has recommended radiofrequency thermal coagulation. The Health Plan considers this procedure experimental and has denied the patients request for authorization and coverage.The proposed radiofrequency ablation is an experimental procedure without established safety and efficacy. There is no Class I long-term data demonstrating an advantage to this procedure over more established therapeutic interventions for the treatment of occipital neuralgia. The long-term safety profile is unknown and complications may be severe. Based on these considerations, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.