Occipital Nerve Block Injection 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 occipital nerve block injection. Current medical literature supports the safety and efficacy of occipital nerve blocks as the initial treatment of choice for occipital neuralgia. The International Headache Society (IHS) defines occipital neuralgia as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser, and/or third occipital nerves. The IHS notes that tenderness to palpation over the affected nerve with temporary pain relief after an anesthetic block is also required to meet the definition. Pain may be unilateral or bilateral, with radiation into the temple or even behind the eye commonly triggered by head movements.

Findings: The physician reviewer found that the patient requested reimbursement and prospective authorization and coverage for occipital nerve block injections provided every three (3) months.According to the International Headache Society Classification, occipital neuralgia is defined as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distributions of the greater, lesser, and/or third occipital nerves. In addition, the pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements. Occipital nerve block (ONB) is the initial standard treatment for occipital neuralgia. For patients with occipital neuralgia who have moderate to severe pain or debilitating symptoms, a local occipital nerve block is recommended. Further, the procedure is generally safe and can be repeated when pain recurs.

Where the denial was upheld

The patient has requested authorization and coverage for trigger point injection, occipital nerve block injection, and peripheral nerve block injection. The American Headache Society noted that there is a paucity of evidence from controlled studies for the use of peripheral nerve blocks in the treatment of primary and secondary headache disorders, with the exception of greater occipital nerve blockade for cluster headaches. The consensus guidelines did not find evidence to support using occipital nerve blocks and trigger point injections for occipital neuralgia as the best evidence is for cluster headaches. Researchers found limited data on the efficacy of peripheral nerve blocks and trigger point injections for the treatment of headache syndromes.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the occipital nerve block injection that was received and/or authorization and coverage for future injections. The Health Plan has denied the services at issue as investigational. Findings: Two out of three physician reviewers found that greater occipital nerve blocks are a simple, safe and effective method, with mild side effects and can be used in patients with inadequate pain relief in spite of medical prophylaxis, or in those who have not tolerated medical treatment. Compared to control intervention, GONB intervention can significantly alleviate pain, reduce the number of headache days and medication consumption, but have no significant influence on the duration of a headache per four weeks for migraine patients.

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