Chronic Headache: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services. Findings: The physician reviewer found that a study opined acupuncture provided highly significant and clinically relevant improvements in treating patients with chronic headaches. In addition, the study noted acupuncture could be a valuable non-pharmacological tool for patients with frequent episodic or chronic tension-type headaches. Regarding this patient’s chronic pain, another study noted that acupuncture is effective for the treatment of chronic pain. In reviewing the records available, it does not appear that the patient has undergone an acupuncture trial. Given the patient’s continued symptoms, an acupuncture trial is reasonable and supported by the peer-reviewed medical literature.

Nature of Statutory Criteria/Case Summary: An enrollee has requested occipital nerve stimulation for treatment of the enrollee’s medical condition. Findings: Two physician reviewers found that although occipital nerve stimulation is not a first-line therapy for chronic headaches, there is adequate clinical trials that demonstrate its use and safety in select populations of patients. In this particular case, the patient has failed many first-line therapies and has a contraindication to other headache therapies. The patient has significant limitations secondary to his headaches. Undertreated headaches are an unnecessary cause of functional impairment. To this end, a trial of occipital nerve stimulation is a reasonable approach in this particular case.

Where the denial was upheld

A 25-year-old male has requested coverage for occipital nerve stimulation (implantable neurostimulator electrode L8680 x 2, electronic analysis of implanted neurostimulator 95972, and percutaneous implantation of neurostimulator 64555 x 2) for treatment of his headaches. Findings: Two physician reviewers found that the patient has had chronic headaches since childhood. He was diagnosed with cisterna magna/arachnoid cyst at eight years of age. The headaches are localized to the occipital area and spread to the vertex. The patient’s pain interferes with his daily life activities. The patient had a shunt placed at the age of 20, with no relief. The medical records noted that the patient had two occipital nerve blocks, with temporary relief for two weeks each time.

SummaryThe patient is a 34-year-old woman with chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy. The Health Plan has denied authorization for Botox indicating it is not medically necessary. The physician reviewer concluded that the Health Plan denial should be upheld. Analysis and FindingsClinical Facts: The patient has chronic headache associated with neck muscle pain and spasm. She is requesting authorization for Botox therapy. The patient has consistently refused usual migraine preventive therapy. MRIs of the brain and neck were unremarkable. An EMG reported cervical muscle spasm “consistent with dystonia.” Reviewer’s Findings:The reviewer found that although Botox is beneficial for some patients with intractable migraines, it is not appropriate as a first or second line therapy for this condition.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for chronic headache was denied, the published record says the denial is worth fighting.