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Occipital Neuralgia and Headache Treatment

Policy Number: MP-314

Latest Review Date: November 2021

Category:  Surgery                                                                 

POLICY:

The following treatments for chronic headaches, including cervicogenic headache, occipital neuralgia, and migraine is considered investigational.

  • Discectomy and spinal fusion
  • Dorsal column stimulation
  • Electrical stimulation of occipital nerve
  • Ganglionectomy
  • Implantable infusion pumps (refer to Medical Policy #442 for additional information)
  • Injection of anesthetic
  • Nerve root decompression
  • Neurectomy
  • Neurolysis of the great occipital nerve with or without section of the inferior oblique muscle
  • Occipital nerve neurolysis
  • Pulsed radiofrequency
  • Radiofrequency denervation of cervical facet joints
  • Radiofrequency ablation of the planum nuchale
  • Radiofrequency ablation of peripheral nerves
  • Rhizotomy
  • Sphenopalatine Ganglion block
  • Surgical release of the lesser occipital nerve within the trapezius

The safety and effectiveness of these treatments for these indications have not been established.

DESCRIPTION OF PROCEDURE OR SERVICE:

Headache

Headaches are common neurologic disorders and are among the top reasons that patients seek medical care. Headaches affect approximately 50% of the general population in a given year and over 90% of people have a lifetime history of headache. Several treatments or procedures for headache (e.g., chronic migraine, tension-type headache, chronic cluster or cervicogenic headache) and occipital neuralgia have been introduced with varying levels of success. The consensus on standard of care does not exist due to the variability in patient selection and clinical outcomes.

The International Headache Society (IHS), through expert consensus, has created a headache classification system to help diagnose and classify headaches. The IHS criteria are regarded as the gold standard for diagnosis of all types of headaches. The first edition was published in 1988, the second edition was published in 2004 and the third edition was released in early 2018.

The third edition classifies headaches into 3 major groups:

  • The first group, the primary headaches, includes migraine, tension-type headache, cluster headaches, other trigeminal autonomic cephalgias, and other primary headaches;
  • The second group, the secondary headaches, includes headaches attributed to head and/or neck trauma, cranial or cervical vascular disorder, non-vascular intracranial disorder, a substance or its withdrawal, infection, disorder of homeostasis, disorder of cranial, cervical or facial structures, or psychiatric disorder; and
  • The third group includes cranial neuralgias, central or primary facial pain, and other headache disorders.

Primary Headache Disorders

Migraines

Migraines are the second-most common headache disorder with 1-year prevalence of migraine in the United States of approximately 12% and can be categorized by headache frequency.

Migraines are characterized by severe pain on one or both sides of the head, an upset stomach, and, at times, disturbed vision.

According to the Third Edition of the International Headache Classification (ICHD-3), migraine without aura (previously known as common migraine) is defined as at least 5 attacks per month meeting other diagnostic criteria. Chronic migraine is defined as attacks on at least 15 days per month for more than 3 months, with features of migraine on at least 8 days per month.

A variety of medications are used to treat acute migraine episodes. They include medications taken at the onset of an attack to abort the attack (triptans, ergotamines), and medications to treat the pain and other symptoms of migraines once they are established (nonsteroidal anti-inflammatory drugs, narcotic analgesics, antiemetic’s). Prophylactic medication therapy may be appropriate for people with migraines that occur more than 2 days per week. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used in the management of migraine headache. Moreover, botulinum toxin type A injections are a U.S. Food and Drug Administration (FDA) ‒approved treatment for chronic migraine.

Tension-Type Headaches (TTH)

Tension- type headaches (TTH) have a prevalence range from 30% to 78%. They are diagnosed when patients report at least 2 of the following characteristics: bilateral headache location, non-pulsating pain of mild to moderate intensity and headache not aggravated by physical activity. Tension- type headaches tend to be mild in nature and are frequently self-diagnosed and self-treated.

There are three types of TTH: Infrequent episodic, frequent episodic and chronic. Infrequent episodic headache is identified in patients who experience headache episodes less than 1 day per month. Frequent episodic TTH is classified as patients whom experience headache episodes 1 to 14 days per month and chronic TTH is diagnosed in patients who experience headache episodes for 15 days or more per month. Treatment for episodic TTH consists of simple analgesics, simple analgesics with caffeine, parenteral treatments, triptans, and muscle relaxants. Chronic TTH treatment consists of tricyclic antidepressants, behavioral therapies and physical therapy. 

Cluster Headaches

Cluster headaches are less common than tension or migraine headaches, with an estimated prevalence of 0.1% of the population. Cluster headaches are characterized by severe unilateral orbital, supraorbital and/or temporal pain that also includes other symptoms in the eye and/or nose on the same side such as rhinorrhea, eyelid edema, or drooping. Cluster headaches occur in a series lasting for weeks to months. Approximately 10-15% have cluster, periods separated by remission periods which usually lasts for months or years. Due to the severity of pain associated with cluster headaches, patients may seek emergency treatment.

Severe acute cluster headaches may be treated with abortive therapy including breathing 100% oxygen and triptan medications. Other medications used to treat cluster headaches include steroids, calcium channel blockers and nerve pain medications.

Occipital Neuralgia

Occipital neuralgia is a specific type of headache that is located on one side of the upper neck, back of the head, and behind the ears, and sometimes extending to the scalp, forehead, and behind the eyes. The pain, which may be piercing, throbbing, or electric-shock-like, follows the course of the greater and lesser occipital nerves. Occipital neuralgia is believed to occur due to pressure or irritation to the occipital nerves, which may result from injury, entrapment by tight muscles, or inflammation.

Occipital neuralgia results in posterior occipital headaches when pressure occurs on the greater and/or lesser occipital nerves. It may be classified as intermittent (e.g., paroxysmal) or continuous, with an acute or chronic nature. Paroxysmal occipital neuralgia is pain that occurs only in the distribution of the greater occipital nerve. The attacks are unilateral, with sudden and severe pain prescribed as sharp, twisting or lancing. The attacks may occur spontaneously but can be provoked by specific maneuvers applied to the back of the scalp or neck regions.

Acute continuous occipital neuralgia attacks can last for many hours, with duration of up to 2 weeks before remission. This type is not usually associated with radiating facial symptoms. In chronic continuous occipital neuralgia, the attacks are accompanied by localized muscle spasms. The pain is described as steady, sharp or aching, with referred pain into facial areas, especially above and behind the orbit. Unilateral pain is more common, but it can also be bilateral. Scalp tenderness is common. Pain may be increased or be provoked with postures that occur in reading or sleeping positions or with hyperextension or rotation of the head to the involved side. Physical findings include pain with palpation of the occipital nerves. Occasionally, there is hyperesthesia or allodynia in the distribution of the occipital nerve. Local muscle spasm is frequently found with palpable trigger points and taut bands. Cervical range of motion may be restricted, and neurological exams are typically normal. An anesthetic block given at the site of maximal tenderness or at the site of the occipital groove confirms the diagnosis of occipital neuralgia if there is pain relief. Treatment may include massage, rest, muscle relaxants, nerve blocks, or injection of steroids directly into the affected area.

The IHS considers the diagnostic criteria for occipital neuralgia as follows:

  • Paroxysmal, stabbing pain, with or without persistent aching between paroxysms, in the distribution of the greater, lesser, and/or third occipital nerves.
  • Tenderness over the affected nerve.
  • Pain eased temporarily by local anesthetic block of the nerve.

Secondary Headache Disorders

Cervicogenic Headache

Cervicogenic headache is a headache that is secondary to a disorder of the cervical spine. The pain may be referred from facet joints, intervertebral discs, or soft tissue. The pain is constant and may be aggravated by movements of the neck or pressure to certain areas on the neck. The first three cervical spinal nerves can refer pain to the head. The C1 suboccipital nerve innervates the atlanto-occipital joint; the C2 spinal nerve and the C3 dorsal ramus have close proximity to and innervate the C2-C3 facet joint. The C2-3 facet joint is the most frequent source of a cervicogenic headache. A diagnosis of a cervicogenic headache may be confirmed by an anesthetic block of the lateral atlanto-axial joint, the C2-3 facet joint, or the C3-4 facet joint.

Cervicogenic headache and occipital neuralgia are syndromes whose diagnosis and treatment have been reported as controversial in the medical literature due to lack of expert consensus regarding their etiology and treatment. The terminology refers to specific types of headache thought to arise from impingement or entrapment of the occipital nerves and/or the upper spinal vertebrae. Compression and injury of the occipital nerves within the muscles of the neck and compression of the second and third cervical nerve roots are generally thought to be responsible for the symptoms including unilateral and occasionally bilateral head, neck, and arm pain. The convergence of the afferents of the upper 3 cervical spinal nerves is thought to be responsible for this head pain that arises from the neck.

Generally accepted causes of head pain originating in the neck include:

•     Developmental abnormalities, tumors, ankylosing spondylitis, rheumatoid arthritis, and osteomyelitis.

Controversial causes include:

•     Cervical disc herniation, degenerative disc disease, and whiplash injuries.

The prevalence of cervicogenic headache in the general population is about 2.2% and is 4 times more prevalent in women. The clinical features of cervicogenic headache may mimic those associated with primary headache disorders, such as tension-type headache, migraine, or hemicrania continua, so it may be difficult to distinguish among headache types. Cervicogenic headache is characterized by continuous, unilateral head pain radiating from the occipital areas to the frontal area, with associated neck pain and ipsilateral shoulder or arm pain. The headache is non-throbbing and of moderate intensity. It is described as a dull, boring, dragging pain that can fluctuate in intensity. The headache may last from a few hours to several days and, in some cases, for several weeks. The pain is exacerbated by neck movements and is usually caused by neck trauma. Associated symptoms, such as nausea, photophobia, phonophobia, dizziness, blurred vision, and dysphagia may be present, but are generally not pronounced.

The IHS considers the diagnostic criteria for cervicogenic headache as follows:

  • Pain referred from a source in the neck and perceived in one or more regions of the head and/or face.
  • Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, generally accepted as a valid cause of headache.
  • Evidence that the pain can be attributed to the neck disorder or lesion, based on either clinical signs that implicate a source of pain in the neck or abolition of headache following diagnostic nerve block.
  • Pain resolving within three months after successful treatment of causative disorder or lesion.

Sjaastad et al identified another type of CGH with bilateral head and neck pain, aggravated by neck positions and specific occupations such as: hair-dressing, carpentry, and truck/tractor driving. The neck pain precedes or co-exists with the headache, and is aggravated by specific neck movements or sustained postures.

In 2011, Vincent et al described several factors to differentiate CGHs, including:

•Unilateral pain with a facet ‘lock’ irradiating from the back of the head

•Evidence of cervical dysfunction presenting during manual examination

•May occur with trigger point palpation in the head or neck

•Aggravated by sustained neck positions

•Normal imaging

Because the diagnosis of CGH is relatively new, its particular etiology remains unclear.

Treatment of cervicogenic headache (CGH) includes nerve blocks, physical therapy, and exercise.

KEY POINTS:

The most recent literature update was performed through October 1, 2021.

Summary of Evidence

For individuals who have chronic migraine who receive sphenopalatine ganglion blocks, the evidence includes 1 RCT and a case report. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The RCT was double-blind and placebo controlled, and provided a course of 12 SPG blocks over 6 weeks. It found significantly greater short-term (up to 24 hours) benefits of active treatment versus placebo. There were not significant longer-term effects (i.e., 1 and 6 months after a course of 12 treatments). The study was underpowered to detect longer term efficacy. Additional adequately powered RCTs demonstrating efficacy are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have severe acute headache treated in an emergency setting who receive sphenopalatine ganglion blocks, the evidence includes 1 RCT. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. The RCT was double-blind and placebo controlled, and provided a single SPG block. There was not a statistically significant difference between active treatment and placebo in the primary outcome, pain reduction 15 minutes post-intervention. The study did not collect pain data again while patients were in the emergency department (e.g., at 1 hour after treatment). At 24 hours after treatment, significantly more patients were headache-free in the active treatment versus placebo group. However, there is insufficient evidence that 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 sphenopalatine ganglion blocks, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Two small case series were available; the approach to intranasal SPG blocks differed from the intervention currently available in the United States. It is not clear how the safety or efficacy of the procedure used in the case series differs from an intranasal SPG block applying local anesthetics and using an FDA cleared device. In the series, 40-50% of patients experienced complete symptom relief for a variable length of time and about 20% had treatment-related complications. 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.

For individuals who have occipital neuralgia or cervicogenic headache who receive RFA or cryoneurolysis of peripheral nerves, the evidence includes RCTs and systematic reviews of RCTS. Relevant outcomes are symptoms, functional outcomes, and QOL. No RCTs of RFA for chronic occipital neuralgia have been identified. Three RCTs of RFA for a cervicogenic headache have been published, none of which were high quality. Pain is a subjective, patient-reported measure that is particularly susceptible to a placebo effect. Randomized trials with sham or active-controls are needed to evaluate the efficacy of this treatment. One controlled trial found a temporary benefit of cryoneurolysis for cervicogenic headache, but the effect was not significantly better than injection of corticosteroid and local anesthetic. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements

American Academy of Pain Medicine

The American Academy of Pain Medicine (2021) conducted a systematic review to develop practice recommendations for use of percutaneous interventional strategies for the preventive treatment of migraine. Sphenopalatine ganglion blocks received a weak recommendation for chronic migraine prevention based on a very low certainty of evidence. The only therapy evaluated in the guideline that received a strong recommendation for chronic migraine prevention was on a botulinum toxin A.

American Headache Society

In 2019, an AHS position statement on integrating novel migraine treatments into clinical practices, such as, neuromodulation and biobehavioral therapy may be appropriate for preventive and acute treatment, depending on the requirements of individual patients. Neuromodulation may be useful for patients who prefer nondrug therapies or who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy (AHS, 2019).

American Academy of Neurology et al

In 2013, the American Academy of Neurology and American Headache Society updated their joint practice guidelines on migraine prevention in adults; the use of biofeedback was not mentioned in the recommendations.

KEY WORDS:

Cervicogenic headache, occipital neuralgia, migraine headache, Sphenopalatine Ganglion (SPG), Sphenopalatine Ganglion Block, Tx360®, MiRx™ protocol, SpenoCath®, Allevio™, Radiofrequency Ablation (RFA), sphenopalatine ganglion pulsed radiofrequency (SPG-PRF), Pulsed Radiofrequency Ablation (PRFA), cluster headache and tension-type headache.

APPROVED BY GOVERNING BODIES:

The Tx360® Nasal Applicator (Tian Medical), the Allevio™ SPG Nerve Block Catheter (JET Medical), and the SpenoCath® (Dolor Technologies) are considered class I devices by the U.S. Food and Drug Administration (FDA) and are exempt from 510(k) requirements. This classification does not require submission of clinical data regarding efficacy but only notification of FDA prior to marketing. These 3 devices are all used to apply numbing medication intranasally.

U.S. Preventative Services Task Force Recommendations

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING: 

CPT Codes:

There is no specific CPT for sphenopalatine ganglion block. Use the unlisted procedure codes 30999 or 64999.

The use of code 64505 would be inappropriate as the procedure is for a spray application.

30999

Unlisted procedure, nose

63020

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; one interspace, cervical

63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; including open and endoscopically-assisted approaches; each additional interspace, cervical or lumbar (list separately in addition to code for primary procedure)

63040

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical

63043

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (list separately in addition to code for primary procedure)

63045

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equine and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; cervical

63048

Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (list separately in addition to code for primary procedure)

63050

Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments;

63075

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

63076

Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (list separately in addition to code for primary procedure)

63081

Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment

63082

Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (list separately in addition to code for primary procedure)

63185

Laminectomy with rhizotomy; one or two segments

63190             

Laminectomy with rhizotomy; more than two segments

63650

Percutaneous implantation of neurostimulator electrode array, epidural

63655

Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

63661

Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

63662

Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

63663

Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

63664

Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

63685

Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

63688

Revision or removal of implanted spinal neurostimulator pulse generator or receiver

64405

Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve

64450

Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

64555

Percutaneous implantation of neurostimulator electrodes array; peripheral nerve (excludes sacral nerve)

64600

Destruction by neurolytic agent, trigeminal nerve; supraorbital, intraorbital, mental, or inferior alveolar branch

64612

Chemo-denervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (e.g., for blepharospasm, hemifacial spasm)

64615

Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (e.g., for chronic migraine)

64616

Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis)

64633

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or ct); cervical or thoracic, single facet joint

64634

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64640

Destruction by neurolytic agent; other peripheral nerve or branch

64716             

Neuroplasty and/or transposition; cranial nerve (specify)

64722             

Decompression; unspecified nerve(s) (specify)

64727

Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

64744             

Transection or avulsion of; greater occipital nerve

64802             

Sympathectomy, cervical

64804

Sympathectomy, cervicothoracic

64999             

Unlisted procedure, nervous system

95970

Electronic analysis of implanted neurostimulator pulse generator system (e.g. rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e. cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without programming

95971

Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming

                   

HCPCS:

 

E0745

Neuromuscular stimulator, electronic shock unit

J0585

Injection, Onabotulinumtoxin A, one unit

J0587

Injection, Rimabotulinumtoxin B, 100 units

L8679

Implantable neurostimulator, pulse generator, any type

L8680

Implantable neurostimulator electrode (with any number of contact points), each

L8681

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

 

L8682

Implantable neurostimulator radiofrequency receiver

L8683

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8684

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8685

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

L8695

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

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  43. International Association for the Study of Pain (IASP). Epidemiology of Headache. 2011; www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/HeadacheFactSheets/1-Epidemiology.pdf. Accessed April 10, 2017.
  44. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. Jul 2013; 33(9):629-808.
  45. The MiRx™ Protocol www.mirxprotocol.com/. Accessed April 14, 2017.
  46. Jansen J, et al. Cervicogenic headache: Long-term prognosis after neck surgery. Acta Neurology Scandinavia, March 2007; 115(3): 185-191.
  47. Jansen J. Surgical treatment of non-responsive cervicogenic headache. Clinical Experience Rheumatology, March-April 2000; 18(2 Suppl 19); S67-S70.
  48. Jensen S. Neck related causes of headache. Australian Family Physician, August 2005; 34(8): 635-639.
  49. Johnstone CS, et al. Occipital nerve stimulation for the treatment of occipital neuralgia-8 case studies. Pain Medicine, September 2006; 7(5): 467.
  50. Jull GA, et al. Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalgia, February 2005; 25(2): 101-108.
  51. Kapoor V, et al. Refractory occipital neuralgia: Preoperative assessment with CT-guided nerve block prior to dorsal cervical rhizotomy. AJNR, November-December 2003; 24(10): 2105-2110.
  52. Kapural L, et al. Botulinum toxin occipital nerve block for the treatment of severe occipital neuralgia: A case series. Pain Practice, December 2007; 7(4): 337-340.
  53. Kapural L, et al. Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: A pilot study. Anesthesia Analgesia, July 2005; 101(1): 171-174.
  54. Kastler B, Michalakis D, et al. [Stellate ganglion radiofrequency neurolysis under CT guidance. Preliminary study]. JBR-BTR 2001; 84(5): 191-194.
  55. Mariana de Silva, Jr H, et al. Cervicogenic headache. Current Pain Headache Rep, August 2006; 10(4): 306-311.
  56. Martelletti P, et al. Cervicogenic headache: Practical approaches to therapy. CNS Drugs 2004; 18(12): 793-805.
  57. Mellick GA, et al. Regional head and face pain relief following lower cervical intramuscular anesthetic injection. Headache, November-December 2003; 43(10): 1109-1111.
  58. Naja ZM, et al. Occipital nerve blockade for cervicogenic headache: A double-blind randomized controlled clinical trial. Pain Practice, June 2006; 6(2): 89-95.
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POLICY HISTORY:

Medical Policy Group, January 2008 (3)

Medical Policy Administration Committee, February 2008

Available for comment February 9-March 24, 2008

Medical Policy Group, August 2008 (2)

Medical Policy Administration Committee, August 2008

Available for comment, August 13-September 26, 2008

Medical Policy Group, November 2008 (1)

Medical Policy Administration Committee, December 2008

Available for comment February 17-April 2, 2009

Medical Policy Group, August 2010 (3)

Medical Policy Administration Committee, September 2010

Available for comment September 4-October 18, 2010

Medical Policy Group, October 2010

Medical Policy Group, March 2011 (3)

Medical Policy Group, December 2011 (3): 2012 Coding Updates – Added 63030, 64633 and 64634, changed verbiage in 64555, 95970 and 95971 and deleted 64626 and 64627.

Medical Policy Group, December 2012 (3): 2013 Coding Update: Verbiage change 64612 and addition of 64615

Medical Policy Group, June 2013 (3): added bullet for clarification of implantable infusion pumps as injections as non-covered treatment

Medical Policy Group, December 2013 (1): 2014 Coding Update: added new code 64616, effective 01/01/14; moved deleted code 64613 to previous coding, effective 01/01/14

Medical Policy Group, May 2014 (5): 2014 Coding Update:  Deleted code L8680 effective July 1, 2014.

Medical Policy Group, June 2014 (5): Quarterly 2014 Coding Update:  Code L8680 did not delete added back to policy under current codes.

Medical Policy Group, April 2015 (5): Under policy statement removed effective for dates of service on or after October 15, 2010 from Botulinum toxin and just left to refer to MP 074.  No change in policy statement. 

Medical Policy Group, July 2015 (6): Updates to Key Points and References; no change in policy statement.

Medical Policy Group, June 2016 (6): Updates to Policy Statement, Key Points, Key Words Coding and References.

Medical Policy Administration Committee, July 2016

Available for comment June 28 through August 11, 2016

Medical Policy Group, November 2016 (6): Updated coding, added L8679  Implantable neurostimulator, pulse generator, any type.

Medical Policy Group, May 2017 (6): Updates to Description, Key Points, Key Words and Governing Bodies, and References. Included updated information regarding Sphenopalatine Ganglion Block.

Medical Policy Group, October 2017 (6): Removed Botox from policy statement, Botox is a Physician Administered Drug Policy.

Medical Policy Group, December 2017 (6): Removed coding “63030 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar”.

Medical Policy Group, October 2018 (3): Policy statement now includes: “radiofrequency ablation of peripheral nerves”, Added code 64722 to current coding. Updates to Description, Key Points, References and Key Words: added Radiofrequency Ablation (RFA) Sphenopalatine Ganglion Pulsed Radiofrequency (SPG-PRF), Pulsed Radiofrequency Ablation (PRFA).

Medical Policy Group, December 2018 (3): Updates to Key Points, Practice Guidelines and Position Statements, Key Words and References. Added Key Words: tension-type headache and cluster headache. Added research criteria that explores the effects of Sphenopalatine Ganglion Block on Cluster Headache, Severe Acute Headache, and Chronic Migraine. Policy statement unchanged.

Medical Policy Group, November 2019 (3): 2019 Updates to Key Points. No changes to policy statement or intent.

Medical Policy Group, December 2019: 2020 Annual Coding Update.  Revised CPT codes 64405 and 64450. Revision made for standardization of the code descriptors and clarity.

Medical Policy Group, December 2020 (3): 2020 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent. Title changed from Treatment of Cervicogenic Headache and Occipital Neuralgia to Occipital Neuralgia and Headache Treatment.

Medical Policy Group, November 2021 (3): 2021 Updates to Key Points, Practice Guidelines and Position Statements, and References. Policy statement updated to remove “not medically necessary.”

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.