Are retro trigger point injections with occipital nerve block medically necessary for a patient with persistent cervicogenic pain, occipital neuralgia, and myofascial pain syndrome, despite unknown status of failed conservative treatment?

Medical Necessity Determination: Trigger Point Injections and Occipital Nerve Blocks

The requested cervical/thoracic trigger point injections and occipital nerve blocks are NOT medically necessary at this time because documentation does not demonstrate adequate trial and failure of conservative treatment, which is a mandatory prerequisite according to established criteria.

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Critical Missing Documentation

The primary deficiency is the absence of documented failed conservative treatment. 1

• The Aetna criteria explicitly requires that "conservative treatment such as bed rest, exercises, heating or cooling modalities, massage, and pharmacotherapies such as non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, non-narcotic analgesics, should have been tried and failed" - this criterion is NOT MET per the reviewer's own assessment
• While physical therapy and chiropractic treatments were recommended on one date, there is no documentation of:
  • Duration of conservative therapy attempted
  • Specific modalities used
  • Patient compliance with recommendations
  • Objective failure of these interventions
  • Timeline of treatment attempts

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Analysis of Occipital Nerve Block Component

The occipital nerve block request meets diagnostic criteria but still requires conservative treatment failure. 1

Evidence Supporting Occipital Nerve Block for Occipital Neuralgia:

• The 2023 VA/DoD Headache Guidelines provide a weak recommendation FOR greater occipital nerve block for short-term treatment of migraine, though evidence for chronic migraine prevention is insufficient 1
• The patient's documented occipital neuralgia with scalp sensitivity represents an appropriate indication per the AHH exception criteria
• Occipital nerve blocks can provide both diagnostic confirmation and therapeutic benefit for occipital neuralgia 2, 3, 4

Critical Limitation:

• Even with appropriate diagnosis, the 2023 VA/DoD guidelines emphasize that injections should be part of comprehensive pain management including physical therapy, patient education, and oral medication 1
• No documentation exists showing the patient has engaged in or failed these foundational treatments

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Analysis of Trigger Point Injection Component

Trigger point injections for cervical/thoracic myofascial pain lack strong supporting evidence and require documented conservative treatment failure. 1

Evidence Regarding Trigger Point Injections:

• The 2005 neurosurgical guidelines provide only Class III evidence (weakest level) for trigger point injections in chronic pain management 1
• Studies show mixed results, with some demonstrating no superiority over dry needling or even saline injection 1
• The Aetna criteria specifically requires trigger point injections be "provided as part of a comprehensive pain management program, including physical therapy, patient education, psychosocial support, and oral medication" - this is marked as MET, but documentation does not support this claim

Documentation Gaps:

• No evidence of ongoing physical therapy participation
• No documentation of medication trials (NSAIDs, muscle relaxants, etc.) with specific agents, doses, duration, or response
• No evidence of patient education or psychosocial support implementation
• Recommendations made on one visit date do not constitute a comprehensive program

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Specific Deficiencies in Conservative Treatment Documentation

The following conservative modalities should be documented as attempted and failed before proceeding: 1

1. Pharmacotherapy trials (minimum 6-8 weeks each):

   • NSAIDs at therapeutic doses
   • Muscle relaxants
   • Tricyclic antidepressants (amitriptyline) for chronic tension-type headache 1
   • Anticonvulsants for neuropathic pain components

2. Physical therapy (minimum 6-8 weeks):

   • Specific exercises for cervicogenic headache 1
   • Manual therapy techniques
   • Posture correction 4
   • Range of motion exercises

3. Additional conservative modalities:

   • Heat/cold therapy
   • TENS unit trial 4
   • Massage therapy
   • Activity modification

4. Documentation of compliance and response:

   • Patient adherence to recommendations
   • Objective pain scores before and after each intervention
   • Functional outcome measures

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Anticoagulation Consideration

The documented need to review anticoagulation and periprocedural risk further supports deferring injections until conservative treatment is optimized. 1

• The clinical note mentions "review on anticoagulation medication and risk-benefit ratio of discontinuation" is needed before proceeding
• This represents an additional safety concern that should be resolved during the conservative treatment phase
• Optimizing non-invasive treatments eliminates procedural bleeding risk entirely

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Recommended Path Forward

To establish medical necessity, the following must be documented: 1, 4

1. Minimum 8-12 weeks of structured conservative treatment including:

   • Formal physical therapy with documented attendance and progress notes
   • Trial of at least 2-3 different medication classes at therapeutic doses
   • Patient education regarding pain management strategies
   • Home exercise program compliance

2. Objective documentation of treatment failure:

   • Serial pain scores (VAS or numeric rating scale)
   • Functional outcome measures (Neck Disability Index, headache frequency/severity logs)
   • Documentation that symptoms persist despite optimal conservative management

3. Resolution of anticoagulation concerns with documented plan for periprocedural management if injections become indicated

4. Clear documentation that trigger points have been consistently identified on multiple examinations (already partially met)

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Common Pitfalls to Avoid

• Do not proceed with injections based solely on physical examination findings without documented conservative treatment failure 1
• Do not assume patient recommendations equal patient compliance - actual participation in physical therapy and medication trials must be documented 1
• Do not interpret the presence of occipital neuralgia as automatic indication for nerve blocks - the 2023 VA/DoD guidelines provide only weak support and emphasize comprehensive management 1
• Do not overlook that degenerative changes (facet arthropathy, spinal stenosis) correlate poorly with symptoms and may not be the primary pain generators 1, 5, 6

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Final Determination

DENIED - Not Medically Necessary

Rationale: The requested procedures fail to meet established criteria due to absent documentation of adequate conservative treatment trial and failure. While the patient has appropriate diagnoses (occipital neuralgia, cervicogenic headache, myofascial pain syndrome) and identified trigger points, the fundamental requirement for documented failed conservative management over an appropriate timeframe (minimum 3 months per criteria) has not been satisfied. The single notation of recommendations for physical therapy and chiropractic treatment does not constitute a trial of conservative therapy. 1

Required for reconsideration: Documentation of 8-12 weeks of comprehensive conservative treatment including physical therapy attendance records, medication trials with specific agents/doses/responses, and objective evidence of persistent symptoms despite optimal non-invasive management.