Blue Cross Blue Shield Eliminates Coverage for Sphenopalatine Ganglion Blocks.

Dr. Shapira Blog, Dentist 0 Comments

Across the country Blue Cross Blue Shield is eliminating medical coverage for SPG Blocks declaring them experimental.  This is an enormous and costly mistake that will harm patients and increase medical expenses.  There is a better alternative.

Sphenopalatine Ganglion Blocks (SPG Blocks) are often called the “Miracle Block” and were popularized in the 1986 book “Miracles on Park Avenue” which detailed the practice of Dr Milton Reder a New York City ENT whose entire practice was treating a wide variety of medical disorders with SPG Blocks.

They were originally described in 1908 by Sluder and treated Sluder’s Neuralgia.  Today most experts believe Sluder’s Neuralgia was a TMD (TMJ) disorder, Migraine, Cluster Headache or other autonomic cephalgia.  A new study in the International Journal of Cardiology (jan 1, 2018) shows the are successful in treating Essential Hypertension. (abstract below)

There are multiple methods of doing SPG Blocks including intraoral injections, extraoral injections by multiple routes and several methods of transnasal applications including the Sphenocath, the Allevio and the Tx360.  All of those devices are expensive to buy ($75.00 or more) and are designed for a single use usually by a neurologist, ENT, Dentist or family practitioner.

I utilize both injections and the Sphenocath in isolated patients in my practice but the ideal method of delivering Sphenopalatine Ganglion Blocks is for patients to be taught how to self administer the blocks.  After initial appointments the cost of self-administration of SPG Blocks bilaterally is less than $1.00.  They have the additional advantage of continual capillary feed and the ability of patients to move around during treatment.

After initial appointments to learn the technique the cost of blocks is less than $1.00 per application.  Patients self administering the blocks will result in significantly fewer emergency room visits, reduce over-dosage of medication including opiods, reduce doctor visits, decrease anxiety, lower blood pressure and help instill a sense of well being in patients.  It will ultimately save insurance companies a lot of  money.

Some of the new Blue Cross Blue Shield Policies that are denying coverage for SPG Blocks are available by the links at the bottom of this post.  The rationale of BCBS is that SPG Blocks (see excerpt from BCBS MASS at bottom of post) are investigational even after more than 100 years of them being safely administered.

These new policies will increase both patient suffering and medical costs over time.

i propose to Blue Cross that they reconsider this decision and embrace the concept of self-administration of SPG Blocks.   This is relatively inexpensive and will drastically reduce the use of migraine medications and side effects that acompany them.  SPG Blocks are used in the ER when other treatments fail. https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

The following abstract supports the use of self administration of SPG Blocks in Cancer Patients with Intractable Pain.

 1996 Jan-Feb;21(1):68-70.

Patient-administered sphenopalatine ganglion block.

Abstract

BACKGROUND AND OBJECTIVES:

Pain resulting from head and neck cancer can be severe and difficult to manage. Avoiding hospitalization for as long as possible with a reasonable level of comfort requires a number of therapeutic modalities. The usefulness of self-administered sphenopalatine ganglion block was evaluated in a patient with lethal midline granuloma requiring large doses of morphine.

METHODS:

A 30-year-old woman with intractable pain from lethal midline granuloma was taught to self-administer 4% lidocaine, 1.5 mL topically into each nostril three times per day.

RESULTS:

A 3-month follow-up examination showed substantial pain relief and reduction in morphine requirement. No adverse side effects or complications developed.

CONCLUSIONS:

In certain patients, sphenopalatine ganglion block can be effectively self-administered at home to manage chronic pain.

Bilateral sphenopalatine ganglion block reduces blood pressure in never treated patients with essential hypertension. A randomized controlled single-blinded study.

Triantafyllidi H, Arvaniti C, Schoinas A, Benas D, Vlachos S, Palaiodimos L, Pavlidis G, Ikonomidis I, Batistaki C, Voumvourakis C, Lekakis J.

Int J Cardiol. 2018 Jan 1;250:233-239. doi: 10.1016/j.ijcard.2017.10.042. Epub 2017 Oct 16.

PMID:
29074041
2.

Infiltration of the sphenopalatine ganglion decreases blood pressure in newly diagnosed and never treated patients with essential hypertension.

Triantafyllidi H, Arvaniti C, Palaiodimos L, Vlachos S, Schoinas A, Batistaki C, Kostopanagiotou G, Lekakis J.

Int J Cardiol. 2016 Nov 15;223:345-351. doi: 10.1016/j.ijcard.2016.08.230. Epub 2016 Aug 13.

 

North Carolia

https://www.bluecrossnc.com/sites/default/files/document/attachment/services/public/pdfs/medicalpolicy/sphenopalatine_ganglion_block_for_headache.pdf

Massachustetts

http://www.bluecrossma.com/common/en_US/medical_policies/026%20Sphenopalatine%20Ganglion%20Block%20for%20Headache%20prn.pdf

Arizona

https://www.azblue.com/~/media/azblue/files/healthcare/resources/medical-coverage-guidelines/medicine/o978.pdf

Kansas

https://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/SphenopalatineGanglionBlock_Headache_2017-09-28.pdf

Florida

http://mcgs.bcbsfl.com/?doc=Nerve%20Block%20Injections

Wellmark BCBS

https://www.wellmark.com/Provider/MedpoliciesAndAuthorizations/MedicalPolicies/policies/Anesth_Sphenopalatine_Ganglion_Headache.aspx

Alabama

https://providers.bcbsal.org/portal/documents/10226/1791629/Treatment+of+Cervicogenic+Headache+and+Occipital+Neuralgia/0e526fdc-25e3-4e46-b6b1-d53dee81c4ed?version=1.2

Texas

https://www.bcbstx.com/provider/news/2015_07_29.html

Below is information taken from BCBS of Massachusetts policy on SPG Blocks.

Sphenopalatine Ganglion Block Sphenopalatine ganglion (SPG) blocks are a proposed treatment option for chronic migraines and some severe non-migraine headaches. The SPG is a group of nerve cells located behind the bony structures of the nose. The nerve bundle is linked to the trigeminal nerve, the primary nerve involved in headache disorders. The SPG has both autonomic nerves, which in this case are associated with functions such as tearing and nasal congestion, and sensory nerves, associated with pain perception. SPG blocks involve topical application of local anesthetic to mucosa overlying the SPG. The rationale for using SPG blocks to treat headaches is that local anesthetics in low concentrations could block the sensory fibers and thereby reduce pain while maintaining autonomic function. 3 The proposed procedure for SPG blockade is to insert intranasally a catheter that is attached to a syringe carrying local anesthetic (eg, lidocaine, bupivacaine). Once the catheter is in place, the local anesthetic is applied to the posterior wall of the nasal cavity and reaches the SPG. Some form of SPG blocking procedure has been used for many years. Originally, SPG blocks were done by inserting a cotton-tipped applicator dabbed with local anesthetic into the nose; this technique may be less accurate and effective than the currently proposed procedure. Another variation is to insert a needle into the cheek and inject local anesthetic but this no longer appears to be used because it is more invasive and can be painful. Neurostimulation of the SPG and SPG blockade with radiofrequency lesioning have been used outside of the United States, but these treatments are not cleared or approved by FDA. Three catheter devices are commercially available in the United States for performing SPG blocks. The catheters have somewhat different designs but all are attached to syringes that contain local anesthetic. The catheters are inserted intranasally and, once in place, the local anesthetic is applied through the catheter. With 2 of the 3 commercially available catheters (the SpenoCath®, AllevioTM), patients are positioned on their back with their nose pointed vertically and their head turned to the side. With the Tx360® device, patients remain seated. The company marketing the Tx360® device proposes its use in the context of the MiRxTM protocol. This 2- part protocol includes a medical component for immediate pain relief and a physical component to reduce headache recurrences. The medical component involves clinical evaluation and, if the patient is considered eligible, an SPG block procedure. The physical component can include any of a number of approaches such as physical therapy, ergonomic modifications, massage, and dietary recommendations. The optimal number and frequency of SPG treatments is unclear. Information from the American Migraine Foundation suggests that the procedure can be repeated as often as needed to control pain. A randomized controlled trial (RCT) has described a course of treatment for migraines consisting of SPG blocks twice a week for 6 weeks (total, 12 treatments). SGB blocks are proposed for both short- and long-term treatment of headaches and migraines. When used in the emergency setting in patients with severe acute headaches, the goal of treatment is to abort the current headache while the patient is in the emergency department. In the RCT that provided a 6- week course of treatment with SPG blocks for chronic migraine (mentioned above), short-term outcomes were assessed up to 24 hours after each treatment, and the duration and frequency of chronic migraines were assessed at 1 and 6 months after the course of treatment. Summary For individuals who have chronic migraine who receive sphenopalatine ganglion (SPG) block(s), the evidence includes a randomized controlled trial (RCT) and a case report. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The randomized trial evaluated a regimen of 12 SPG blocks over 6 weeks and was double-blind and placebo-controlled. The trial found significantly greater short-term (up to 24 hours) benefits from active treatment than from placebo. There were no significant longer term effects (ie, 1 and 6 months after 12 treatments), although the trial was underpowered to detect longer term efficacy. Given that SPG blocks are being proposed as a preventive therapy for chronic migraines, evidence demonstrating reduced migraine frequency, severity, or other objective outcomes from robust trials is still needed. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have severe acute headache treated in the emergency setting who receive SPG block(s), the evidence includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The randomized, double-blind, placebo-controlled trial was evaluated a single SPG block for severe acute headache of mixed etiologies. There was no statistically significant difference between active treatment and placebo for the primary outcome (pain reduction 15 minutes postintervention). The trialists did not collect pain again data until 24 hours posttreatment, at which time significantly more patients were headache-free in the active treatment arm than in the placebo 4 arm. Additional studies, preferably RCTs, are needed to determine whether SPG blocks are an effective treatment in the emergency setting. The evidence is insufficient to determine the effects of the technology on health outcomes. For individuals who have cluster headache who receive SPG block(s), the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Two small case series, both of which evaluate an approach for intranasal SPG blocks that differs from the intervention currently available in the United States, were identified. In these series, 40% to 50% of patients experienced complete symptom relief for a variable length of time and about 20% had treatmentrelated complications. However, it is not clear from these series the degree to which the procedures evaluated differ in safety and efficacy from an intranasal SPG block using a device cleared by the Food and Drug Administration. Additional studies, preferably RCTs, are needed to evaluate SPG blocks for treating cluster headaches. The evidence is insufficient to determine the effects of the technology on health outcomes.

Leave a Reply

Your email address will not be published. Required fields are marked *