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Nerve Block denials: what the review data shows
Independent reviewers have decided 247 published cases where an insurer denied Nerve Block — and they overturned the insurer 59.1% of the time. A denial for Nerve Block is a starting position, not a final answer.
Published decisions
247
2001–2026
Overturned
59.1%
146 denials reversed
Conditions behind nerve block denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Migraine | 45 | 66.7% |
| Back Pain | 41 | 58.5% |
| Headache | 30 | 76.7% |
| Neck Problem Pain | 13 | 69.2% |
| Vertebral Disc Prob | 13 | 46.2% |
| Knee Problem Pain | 11 | 72.7% |
| Osteoarthritis | 10 | 40% |
| Peripheral Neuropathy | 6 | 50% |
| Joint Problem Pain | 4 | 25% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 155 | 61.9% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 92 | 54.3% |
Typical time to a decision
13 days
Most land between 6 and 21 days
Handled as urgent
51.8%
Expedited when a delay would cause harm
Recent direction
Rising
65.4% → 76.1% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
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
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested The patient has requested authorization and coverage for bilateral intraarticular facet joint injections at L4-L5 and L5-S1 (CPT 64493 and 64494). Chou and colleagues note that despite debate regarding the appropriate use of therapeutic modalities in managing lumbar facet joint pain, the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. In a study of the effectiveness of lumbar facet joint blocks, Cohen and colleagues report facet blocks are not therapeutic and that higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve blocks (lidocaine/bupivacaine) every three months. Findings: The physician reviewer found that medical literature notes that medication treatment for occipital neuralgia is not deemed significantly effective, with no more than a few small case series on any medication, while multiple retrospective series demonstrate the effectiveness of occipital nerve blocks for occipital neuralgia.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Nerve Blockwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.