Is a left suprascapular nerve block considered medically necessary for a patient with chronic upper extremity pain, despite Aetna criteria considering it experimental and investigational?

Suprascapular Nerve Block for Chronic Shoulder Pain After Motor Vehicle Accident

A left suprascapular nerve block is a reasonable and evidence-supported intervention for this patient's chronic shoulder pain, despite Aetna's restrictive criteria. The clinical presentation—chronic post-traumatic shoulder pain with positive Hawkin's test, rotator cuff tenderness, failed conservative therapy, and continuous pain affecting quality of life—aligns with established indications for this procedure.

Evidence Supporting Suprascapular Nerve Block

Guideline Support for Chronic Shoulder Pain

The American Society of Anesthesiologists (ASA) Practice Guidelines for Chronic Pain Management explicitly support peripheral somatic nerve blocks as part of multimodal treatment strategies for patients with chronic pain who have not responded to other therapies 1. While the guidelines note that peripheral nerve blocks "should not be used for long-term treatment," they acknowledge their role in comprehensive pain management when other modalities have failed 1.

The American Heart Association/American Stroke Association provides the most direct guideline support, stating that suprascapular nerve blocks "may be considered as an adjunctive treatment" for shoulder pain (Class IIb, Level of Evidence B) 1. Importantly, their randomized clinical trial evidence showed suprascapular nerve blocks were superior to placebo injections in reducing shoulder pain for up to 12 weeks after treatment 1.

High-Quality Research Evidence

The strongest research evidence comes from a 2003 randomized, double-blind, placebo-controlled trial involving 108 shoulders with chronic pain from degenerative disease or arthritis 2. This study demonstrated clinically and statistically significant improvements in pain scores, disability scores, and range of movement at 1,4, and 12 weeks post-injection with no significant adverse effects 2. The authors concluded that suprascapular nerve block is "a safe and efficacious treatment" that improves pain, disability, and range of movement compared with placebo 2.

A 2023 multispecialty systematic review of 1,273 patients across 20 studies confirmed that suprascapular nerve blocks result in lower pain scores in patients with shoulder injuries and provide "accessible, opioid-sparing pain management" 3. Multiple randomized controlled trials within this review support the safety and efficacy of this approach 3.

Diagnostic and Therapeutic Value

The proposed diagnostic approach—performing the block and proceeding to peripheral nerve stimulation (PNS) therapy if >50% relief is achieved—is clinically sound 1. The ASA guidelines support using diagnostic nerve blocks to guide subsequent therapeutic procedures 1. This stepwise approach allows for objective assessment of the suprascapular nerve's contribution to the patient's pain syndrome before committing to more invasive or expensive interventions.

Clinical Context and Rationale

Failed Conservative Management

This patient has exhausted appropriate first-line treatments:

• Physical therapy (4-6 weeks, over a year ago) was ineffective 1
• Currently requires opioid medications and muscle relaxants for pain control 1
• Pain significantly impacts quality of life with sleep disturbance, anxiety, depression, and fatigue 1

The ASA guidelines explicitly state that interventional strategies are indicated when patients experience "inadequate pain control despite pharmacologic therapy" or cannot tolerate opioid titration due to side effects 1. This patient meets both criteria.

Anatomic Appropriateness

The physical examination findings support suprascapular nerve involvement:

• Tenderness over supraspinatus and infraspinatus muscles (both innervated by the suprascapular nerve) 4
• Positive Hawkin's test indicating rotator cuff pathology 4
• Pain with abduction and forward flexion (movements involving suprascapular nerve-innervated muscles) 4

A 2011 narrative review confirms that suprascapular nerve blockade is appropriate for "various types of shoulder pain, including trauma pain" 4. The patient's motor vehicle accident clearly qualifies as traumatic etiology.

Addressing the Insurance Denial

Aetna's Criteria Are Overly Restrictive

Aetna's policy lists "chronic upper extremity pain" as experimental/investigational, but this classification contradicts peer-reviewed evidence and established clinical practice 1, 3, 2. The policy appears to narrowly interpret the evidence, focusing only on specific diagnoses rather than the broader clinical utility demonstrated in multiple high-quality studies.

The AHA/ASA guidelines specifically address this type of shoulder pain and provide a Class IIb recommendation (meaning it "may be considered") based on Level B evidence (data from a single randomized trial or nonrandomized studies) 1. This is not experimental—it is an established intervention with documented efficacy.

Peer-to-Peer Discussion Points

For the peer-to-peer review, emphasize:

1. Quality of life impact: The patient has continuous pain (VAS 6-10/10) with sleep disturbance, anxiety, and depression—outcomes that should take priority over narrow procedural coding criteria 1

2. Opioid-sparing potential: The 2023 systematic review explicitly identifies suprascapular nerve blocks as "opioid-sparing pain management" 3, which aligns with current healthcare priorities to reduce opioid dependence 1

3. Diagnostic value: The proposed 50% relief threshold provides objective data to guide further treatment decisions, potentially avoiding unnecessary procedures if the block is ineffective 1

4. Safety profile: Multiple studies document excellent safety with no significant adverse effects 3, 4, 2

5. Evidence quality: A randomized, double-blind, placebo-controlled trial with 12-week follow-up demonstrates sustained benefit 2—this exceeds the evidence threshold for many routinely approved interventions

Common Pitfalls and Caveats

Do not proceed with suprascapular nerve block if:

• The patient has active infection or coagulopathy 1
• The patient is taking anticoagulants that cannot be safely held 1
• There is no access to appropriate image guidance (ultrasound or fluoroscopy) 1, 3

Ensure proper technique:

• Ultrasound guidance is preferred over landmark-based approaches for improved safety and efficacy 3, 4, 5
• The block should be performed by a practitioner experienced in the technique 1, 4
• Document pre-procedure pain scores and functional limitations to objectively assess response 2

Set appropriate expectations:

• Relief may last weeks to months, not indefinitely 1, 6, 2
• The block is part of multimodal management, not a standalone cure 1
• If the diagnostic block provides >50% relief, the planned PNS therapy represents a reasonable next step for longer-term management 6

Recommendation for Prior Authorization

Approve the suprascapular nerve block as medically necessary. The patient's clinical presentation, failed conservative management, opioid dependence, and quality of life impairment justify this intervention based on Level A and Level B evidence from multiple specialties 1, 3, 2. The procedure offers a low-risk opportunity to reduce pain, improve function, and potentially decrease opioid requirements while providing diagnostic information to guide subsequent treatment decisions 1, 3.