Occipital Neuralgia denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: A review of the records indicates that on 12/3/18, the patient presented to her provider for follow-up regarding ongoing migraines. Findings: The physician reviewer found that this patient rated her pain as 10 on a scale of 10 at worst, and an 8 of 10 at present. Previous treatments included medication therapy, physical therapy, epidural blocks, and Botox injections. Nerve block injections were administered to the left side. On 12/5/18, the patient reported that her pain decreased from 8 of 10 to 2-3 of 10 following the nerve block injections. Injections were then repeated. She reported that her pain decreased from 8 of 10 to 1-6 of 10. The Health Plan indicates that the injection at issue was not likely to have been more beneficial for the treatment of the patient’s condition than any available standard therapy.

Where the denial was upheld

Physician 1: The patient is a 30-year-old female with a history of chronic headache pain diagnosed as occipital neuralgia. The patient reports her symptoms first occurred subsequent to surgical resection of an osteoma in 1996. Various oral medications such as Darvocet, Imitrex, gabapentin, Vicodin, Fioricet and Ultram have been tried. While somewhat effective, in most cases the degree of the pain relief has been limited by the occurrence of side effects. No other oral medication trials are described. Radiofrequency neural thermocoagulation was suggested by the patient’s provider, but the treatment was not authorized. The current recommendation of the patient’s provider is for placement of an occipital nerve stimulator.

Physician 1The patient is a 64-year-old woman who has been experiencing headaches, cervical muscle spasms, occipital neuralgia, and cervical pain due to cervical spine degenerative disc disease. A number of treatment modalities have been tried without providing satisfactory relief. Injections of botulinum toxin have provided effective relief of pain and muscle spasms. The patient wishes to continue treatment with botulinum toxin. The consultations with her pain specialist indicate that a variety of medications and treatments have been tried since 1/5/04 without significant relief. The patient reports that injections of botulinum toxin provide relief for two months. She wishes to receive additional botulinum toxin injections.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving occipital neuralgia, then check the rights and deadlines that apply to your plan.