Trigeminal Neuralgia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) occipital nerve block, (2) trigeminal nerve block, and/or (3) rhizotomy. In a review of established treatment modalities for trigeminal neuralgia, researchers state regarding nerve blocks and follow-up rhizotomy/ablation procedures, “Local anesthetic injections may provide relief in many patients and can be used as a diagnostic tool followed by nerve ablation or stimulation. The most common targets are the supraorbital, infraorbital, auriculotemporal, and mental nerves, but blocks of deeper branches, including the mandibular and maxillary nerves, can also be performed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for opioid pain management for treatment of the enrollee’s right trigeminal neuralgia and migraine. Findings: The physician reviewer found that that opioid risk mitigation tools should be part of practice and when patient safety issues are identified, such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Opioids are generally not recommended as first-line therapy and when used providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse and opioids should be tapered when patient safety risks are identified.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for OxyContin provided, and future for OxyContin 60 mg three times per day (90 tablets per 30 days) for a total of 12 consecutive months without interruption. Findings: The physician reviewer found that records provided for review document that this patient presents with multiple diagnoses, including trigeminal neuralgia, fibromyalgia, degenerative disc disease, and chronic migraines. The patient has been treated on a long-term basis with high doses of OxyContin. The patient has requested continued treatment with OxyContin. Opioids are typically not recommended for the treatment of patients with fibromyalgia or chronic migraines.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous (IV) ketamine infusion treatment (including ketamine push and ketamine infusion). This patient’s records document a history of left-sided facial pain. The patient is status post previous microvascular decompression (MVD) with complete resolution of pain and left redo craniotomy for MVD of trigeminal neuralgia. The patient has requested treatment with IV ketamine infusions. Based on the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine guidelines, the evidence for ketamine infusions in the management of pain conditions such as mixed neuropathic pain is grade D, with low certainty.

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 trigeminal neuralgia, then check the rights and deadlines that apply to your plan.