Occipital nerve blocks and managed care: a review of the reviewers.

Denial of an insurance claim for occipital nerve blocks raises questions about utilization review by insurance companies and peer reviewers. Who reviews the reviewers? CLINICAL HISTORY A 40-year-old man presented with a 3-week history of right-sided more than left nuchal-occipital and parietal throbbing pain of moderate intensity daily on an intermittent basis and lasting for several hours. There was no associated nausea, light or noise sensitivity , aura, fever, or other systemic symptoms. He reported no antecedent history of head or neck trauma. Ibuprofen did not help. There was no prior history of significant headaches. Past medical history was unre-markable. Examination revealed marked tenderness to pal-pation bilaterally (right more than left) over the mid superior nuchal line, with radiating pain which reproduced the patient's headache. Neurologic examination was normal. Bilateral greater occipital nerve blocks were performed with 3 cc each of 1% lidocaine to each side. Complete relief of the headaches resulted and they did not recur. A charge for the occipital nerve blocks was submitted to the patient's insurance company (one of the nation's largest) and subsequently was denied. In the written denial was the following: " Injection of local anesthetics and/or steroids are not medically necessary for treatment of occipital neuralgia that is of unknown etiology and not attributable to organic disease of the head and neck, because their effectiveness has not been clearly demonstrated in peer-reviewed medical literature. Therefore, benefits are not available under the plan. " I appealed and sent material from peer-reviewed journals and from Adams, Victor , and Ropper's Principles of Neurology which spoke to the benefits of occipital nerve blocks. The insurance company medical director replied: " The medical staff and an independent physician consultant, board certified in neurology, reviewed the medical documentation submitted for the final appeal. This review confirms our initial determination that the occipital nerve block injections, CPT code 64405, do not meet our medical necessity guidelines. In order for a test or service to be covered under the plan, it must be commonly and customarily recognized as an acceptable and appropriate test or service for the diagnosis or treatment of a specified condition according to general medical standards of the medical community at large.. .. . medical necessity guidelines are based on valid evidence published in the peer reviewed medical literature to support the effectiveness of the test or service in question. A literature search did not reveal the …