Expert Opinion - rwevansmd.com

1 Expert Opinion 990 Occipital Nerve Blocks and Managed Care:A Review of the Reviewers Case History and Follow-up Submitted by Randolph W. Evans, MD Expert Opinion by George D. Yannakakis, MD Key words: intractable headaches, occipital nerve block ( Headache . 2001;41:990-991) Denial of an insurance claim for occipital nerveblocks raises questions about utilization review by in-surance companies and peer reviewers. Who reviewsthe reviewers? CLINICAL HISTORY A 40-year-old man presented with a 3-week his-tory of right-sided more than left nuchal-occipital andparietal throbbing pain of moderate intensity daily onan intermittent basis and lasting for several was no associated nausea, light or noise sensi-tivity, aura, fever, or other systemic symptoms. He re-ported no antecedent history of head or neck did not help.

2 There was no prior history ofsignificant headaches. Past medical history was revealed marked tenderness to pal-pation bilaterally (right more than left) over the midsuperior nuchal line, with radiating pain which repro-duced the patient s headache. Neurologic examina-tion was normal. Bilateral greater occipital nerveblocks were performed with 3 cc each of 1% lidocaineto each side. Complete relief of the headaches re-sulted and they did not charge for the occipital nerve blocks was sub-mitted to the patient s insurance company (one of thenation s largest) and subsequently was denied. In thewritten denial was the following: Injection of localanesthetics and/or steroids are not medically neces-sary for treatment of occipital neuralgia that is of un-known etiology and not attributable to organic dis-ease of the head and neck, because their effectivenesshas not been clearly demonstrated in peer-reviewedmedical literature.

3 Therefore, benefits are not avail-able under the plan. I appealed and sent materialfrom peer-reviewed journals and from Adams, Vic-tor, and Ropper s Principles of Neurology whichspoke to the benefits of occipital nerve insurance company medical director replied: The medical staff and an independent physicianconsultant, board certified in neurology, reviewed themedical documentation submitted for the final ap-peal. This review confirms our initial determinationthat the occipital nerve block injections, CPT code64405, do not meet our medical necessity order for a test or service to be covered underthe plan, it must be commonly and customarily recog-nized as an acceptable and appropriate test or servicefor the diagnosis or treatment of a specified conditionaccording to general medical standards of the medi-cal community at.

4 Medical necessity guidelines are based onvalid evidence published in the peer reviewed medi-cal literature to support the effectiveness of the testor service in question. A literature search did not re-veal the occipital nerve block injections to be proveneffective in the treatment of occipital neuralgia or un-known origin.. the medical necessity for occipitalnerve block injections has not been , benefits are not available under the plan. Address all correspondence to Dr. Randolph W. Evans, Suite1370, 1200 Binz, Houston, TX 77004 or Dr. George D. Yanna-kakis, Suite 1312, 28 Allegheny Avenue, Towson, MD 21204. Headache 991 Please be advised that a final appeal has beencompleted on the case. There are no further appealsteps available with us.

5 Question. Do you agree with this decision bythe insurance company s medical director and thepeer reviewer? Expert COMMENTARY The patient presented with the recent onset ofheadaches which possessed some features of mi-graine, cluster, and occipital neuralgia, but not fea-tures sufficient to fulfill the criteria required for diag-nosis of any of these according to the InternationalHeadache Society classification system. He wastreated (appropriately) with bilateral occipital nerveblocks, the only treatment, in my experience, whichcan provide acute and lasting relief and is devoid ofside effects. Medical practitioners have been per-forming occipital nerve blocks for the treatment ofintractable headaches for at least the past 6 decades(because of the dramatic relief such treatment canprovide).

6 They have tended to refer to the headacheso treated as occipital neuralgia because of themarked tenderness to palpation (which accompaniesthe headache) in the region of the greater occipitalnerve. In so doing, they made a clinical sign into a dis-ease 1 advocated a role for the occipital nervein the generation of headache by noting strangely, inseveral cases, one or two injections of procaine hy-drochloride have been effective in giving relief fromheadache for several years with no recurrence todate. Parelson 2 reported that tenderness of thegreater occipital nerve was the most common sign ac-companying chronic headaches, regardless of etiol-ogy, and he suggested occipital nerve injections forthose with a benign source.

7 Gawel and Rothbart 3 found that a number of patients with migraine whoexhibited sensitivity around the greater occipitalnerve, failed to respond to standard migraine therapybut responded to steroid-containing occipital and Mustonen 4 found injection of local anes-thetic an extremely effective treatment, theorizingthat migraine itself may initiate greater occipital neu-ralgia. Anthony 5,6 revealed that injection of methyl-prednisolone around the greater occipital nerve waseffective in aborting an attack and conferring prophy-laxis for the great majority of patients with migraine,cluster headache, and occipital neuralgia. Caputi andFiretto 7 found occipital nerve blocks to be effective inthe acute and chronic treatment of migraine.

8 Yanna-kakis found occipital nerve blocks containing a ste-roid to be effective acute and chronic therapy for agroup of patients with intractable lateralized head-aches (mostly migrainous). 8 Based on the reports summarized above, com-mon sense, and my continuing personal experience, Idisagree with the insurance company s medical direc-tor and the peer reviewer. REFERENCES 1. Hadden SB. Neuralgic headache and facial pain. Arch Neurol. 1940;43 Parelson HN. Occipital nerve tenderness. A sign ofheadache. South Med J. 1947;40 Gawel MJ, Rothbart PJ. Occipital nerve block in themanagement of headache and cervical pain. Cephala-lgia. 1992;12 Knox DL, Mustonen E. Greater occipital neuralgia:an ocular pain syndrome with multiple etiologies.

9 Trans Am Acad Ophthalmol Otolaryngol. 1975;79 Anthony M. Unilateral migraine or occipital neural-gia? In: Clifford Rose F, ed. New Advances in Head-ache Research. London: Smith-Gordon; 1989 Anthony M. The role of the occipital nerve in unilateralheadache. In: Clifford Rose F, ed. Advances in Head-ache Research. London: John Libbey; 1987 Caputi CA. Firetto V. Therapeutic blockade ofgreater occipital and supraorbital nerves in migrainepatients. Headache. 1997;37 Yannakakis GD. Occipital nerve block in intractablelateralized headaches: an effective treatment [ab-stract]. Headache. 1999;39:386-387. FOLLOW-UP This insurance company has denied every claimsubmitted for occipital nerve blocks in other medical director and/or his representative wasinvited to rebut this article but declined.