Is an intercostal nerve block medically indicated for a patient with scapular pain, left hand numbness, and a history of failed treatments including Botox (botulinum toxin) injection and denervation, for the management of acute intercostal pain or chronic intercostal neuritis?

Intercostal Nerve Block is NOT Medically Indicated for This Patient

This patient's pain is primarily scapular and cervical in origin, not intercostal, making intercostal nerve blocks anatomically inappropriate and unlikely to provide meaningful benefit. The proposed intervention targets the wrong anatomical location and pain generator.

Critical Mismatch Between Pain Location and Proposed Intervention

• The patient's pain is periscapular (around the shoulder blade) and cervical in nature, not thoracic wall or intercostal pain 1, 2
• Intercostal nerve blocks are specifically indicated for pain in the distribution of intercostal nerves—meaning chest wall pain, rib pain, or thoracic dermatomal pain—not scapular or neck pain 3, 4
• The patient's previous positive response to cervical medial branch blocks (95-98% pain improvement) confirms the pain generator is cervical facet-mediated, not intercostal 1
• Intercostal nerve blocks are recommended for acute intercostal pain or chronic intercostal neuritis as part of comprehensive pain management, neither of which applies to this patient's presentation 5, 1

Evidence Against This Intervention

• The patient describes "periscapular pain" that is "stabbing in character" with radiation into the left arm and occasional left hand numbness—this is a classic cervical radiculopathy or myofascial pain pattern, not intercostal neuralgia 1
• Her pain worsens with fatigue and overuse, and improves with pressure applied to the periscapular region—consistent with myofascial trigger points or cervical-origin referred pain, not intercostal nerve pathology 1
• The provider's own documentation states uncertainty about whether the patient meets criteria for acute intercostal pain or chronic intercostal neuritis, which is a red flag that this intervention is not appropriate 1

What Should Be Done Instead

• Re-evaluate why the cervical radiofrequency denervation failed despite excellent diagnostic block results (95-98% relief) 1

  • Consider technical factors: inadequate lesion size, incorrect needle placement, or incomplete coverage of the medial branch nerves
  • The dramatic response to diagnostic blocks strongly suggests cervical facet-mediated pain that should respond to properly performed denervation 5

• Consider alternative cervical and shoulder-specific interventions 5:

  • Repeat cervical medial branch blocks with longer-acting local anesthetic plus steroid to provide therapeutic benefit while reassessing the pain generator
  • Suprascapular nerve block, which specifically targets periscapular pain and has proven efficacy for shoulder region pain 5
  • Combined suprascapular and axillary nerve blocks for comprehensive shoulder girdle coverage 5

• Address the myofascial component more aggressively 1:

  • The patient's description of pressure to the periscapular region relieving migraine-associated vision changes suggests significant myofascial trigger point involvement
  • Consider dry needling or more extensive trigger point injection series targeting the trapezius, rhomboids, and levator scapulae
  • Physical therapy focused on scapular stabilization and postural correction

Critical Pitfalls to Avoid

• Do not perform procedures targeting anatomically incorrect locations simply because other interventions have failed 5
• The fact that Botox injections to the rhomboid major worsened symptoms suggests either incorrect diagnosis or inappropriate technique—this should prompt diagnostic reconsideration, not a different anatomically mismatched intervention 1
• Intercostal nerve blocks carry risks including pneumothorax (even with ultrasound guidance), and performing them without clear anatomical indication exposes the patient to unnecessary risk without potential benefit 3, 6
• The patient's severe headache following the last procedure (likely post-dural puncture headache from the denervation) indicates she is at risk for complications and should not undergo procedures without clear indication 1

Documentation Does Not Support Medical Necessity

• The clinical documentation explicitly states uncertainty about meeting criteria for intercostal nerve block indications 1
• There is no description of chest wall pain, rib pain, or pain in an intercostal distribution—the fundamental requirements for intercostal nerve block indication 5, 1, 2
• The diagnosis listed is "left shoulder pain, thoracic back pain"—but thoracic back pain alone does not equal intercostal neuralgia, which requires pain in the distribution of specific intercostal nerves 1, 3

Recommendation for Authorization Decision

This request should be denied as not medically indicated. The proposed intervention does not match the patient's pain distribution or likely pain generator. Instead, recommend:

1. Repeat diagnostic cervical medial branch blocks to confirm the pain generator 1
2. If positive, repeat radiofrequency denervation with technical optimization 1
3. Consider suprascapular nerve block as an alternative shoulder-specific intervention 5
4. Comprehensive myofascial treatment program 1