Occipital 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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for occipital nerve block therapy. The management of chronic migraine focuses on prophylactic therapy and avoidance of acute headache medication overuse. Prophylactic interventions may include pharmacotherapy, behavioral therapy, physical therapy, lifestyle modification, neuromodulation, and avoidance of migraine triggers. Management often requires the simultaneous use of these different therapeutic modalities. Peripheral nerve blocks have been used for the acute and preventive treatment of a variety of primary headache disorders for decades. These procedures provide prompt pain relief for many patients with various headache types.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block injections, and authorization and coverage for occipital nerve block injections every three (3) months going forward.Findings: Two out of three physician reviewers found that current medical literature do not support that the services at issue and the requested services are likely to be more beneficial than any other available standard treatments for the patient's medical condition. Dach and colleagues conducted a review in which they considered the role of nerve block in the treatment of headaches and cranial neuralgias. They concluded that the block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for bilateral occipital nerve blocks every six weeks. Barmherzig and Kingston evaluated the current medical evidence and recommendations for the diagnosis and management of occipital neuralgia. The authors concluded that, “Anesthetic block of the greater and/or lesser occipital nerves are often used both diagnostically and therapeutically.” However, the authors concluded that the available “evidence is limited as most studies are noncontrolled.” Urits and colleagues reported that, “Conservative treatments such as medications and alternative therapies are first-line.” The authors discussed treatment options for patients with refractory symptoms to include corticosteroid injections for short-term relief or as a transitional treatment bridge for patients who may bene…

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