Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic migraines.
Treatment: Pain Management; 64400 x 3 (trigeminal nerve block).
The insurer denied coverage for pain Management; 64400 x 3 (trigeminal nerve block).
The denial is upheld.

The patient has a history of headaches. 
An office visit note indicates the patient has headaches four times weekly which originates in the occipital regions. She is currently on Imitrex, and Zofran as needed. The provider indicates the patient has tried and failed "numerous preventative medications including nortriptyline, fluoxetine, propranolol and Topamax" with no relief.

Scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. The patient has migraine headaches, not trigeminal cephalgia or pain in a trigeminal distribution nor does she have cluster headaches. As such, the use of 64400 x 3 (trigeminal nerve block) would not be an improvement in the health of the patient. 

"Trigeminal neuralgia (TN), also known as tic douloureux, is a chronic pain condition characterized by recurrent brief episodes of electric shock-like pains affecting the fifth cranial (trigeminal) nerve, which supplies the forehead, cheek, and lower jaw. This condition is almost always unilateral and can involve one or more divisions of the trigeminal nerve.[1]" (Shankar Kikkeri N, Nagalli S 2022).      

The Trigeminal Nerve Block is appropriate in specific cases.     

The patient is not a good candidate for Pain Management; 64400 x 3 (trigeminal nerve block). The patient has migraine headaches, not trigeminal cephalgia or pain in a trigeminal distribution nor does she have cluster headaches. The patient's pain is migrainous in nature without occipital or trigeminal symptoms.     

Pain Management: 64400 x 3 (trigeminal nerve block) is not the best available treatment for this patient at this time. The patient has migraine headaches, not trigeminal cephalgia or pain in a trigeminal distribution nor does she have cluster headaches. Therefore, 64400 x 3 (trigeminal nerve block) is not medically appropriate for this patient.     
  
The requested procedure is an interventional procedure, however, risks are above standard services, as it is not medically necessary.     

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. The medical records do not indicate that the patient has tried and failed Botox or other Calcitonin gene-related peptide (CGRP) inhibitors. 

"Chronic migraine (CM) is a severely disabling neurological condition characterized by episodes of pulsating unilateral or bilateral headache. The United States Food and Drug Administration (FDA) approved onabotulinumtoxinA (Botox) for the prophylactic treatment of CM in 2010. It has been shown that onabotulinumtoxinA is effective in the reduction of headache frequency and severity in patients with CM. Treatment is well tolerated by the patients." (Escher, C. M., et al., 2017).

"Prescribing the CGRP inhibitor drugs might improve the quality of life for patients with migraine headaches." (Mohanty, D., & Lippmann, S. 2020).                                                    

The carrier's denial of Pain Management; 64400 x 3 (trigeminal nerve block) should be upheld.