Nerve Block 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

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.

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 Nerve Block, then check the rights and deadlines that apply to your plan.