![]() Table: CPT Codes / ICD-10 Codes / HCPCS Codes CodeĬervicogenic, cluster and other chronic headaches:ĬPT codes not covered for indications listed in the CPB: CPB 0292 - Catheter-Directed Cardiac Procedures - f or closure of patent foramen ovale for migraine prophylaxis.Superior turbinate resection, with or without total ethmoidectomy for the treatment of rhinogenic contact point headache.Bilateral temporal branches of facial nerve block, and supratrochlear block for the treatment of headache/neuralgia.Cervical erector spinae plane (ESP) block and rhomboid tendon injections for the treatment of tension/migraine headaches.Subcutaneous peripheral nerve field stimulation for the treatment of nummular headache.Vagus nerve stimulation (e.g., gammaCore nVNS) for the prophylaxis and treatment of cluster and migraine headaches.Ventral tegmental area deep brain stimulation (for the treatment of cluster headaches).Vascular ligation of superficial extracranial arteries.Transposition of cranial sensory nerves.Transection of auriculo-temporal nerves.Topical anesthesia of the sphenopalatine ganglion.Temporal artery ligation ( Note: Temporal artery biopsy is considered medically necessary for diagnosis of suspected temporal arteritis).Resection of any portion of the trigeminal nerve or its branches.Resection of musculature, including but not limited to the corrugator supercilii muscle, or any soft tissue from the forehead, peri-orbital, occipital or other facial or scalp areas manipulation or repositioning of any muscle or other soft tissue within these areas.Resection of the right and left supra-orbital, supra-trochlear and infra-trochlear nerves.Peripheral nerve trigger surgery (nerve excision for the treatment of migraine headache).Migraine trigger site surgery (nerve excision for the treatment of migraine headache).Greater occipital nerve block (for prophylaxis and treatment of migraine headache).Gamma knife (stereotactic) radiosurgery.Decompression of the greater occipital, supra-orbital and supra-trochlear nerves.Bariatric (obesity) surgery for the treatment of migraines.Ablation or electrical stimulation or topical anesthesia of the sphenopalatine ganglion (sphenopalatine ganglion block//sphenopalatine nerve block).Surgical interventions include some of the procedures listed below (not an all-inclusive list): Thermal neurolysis (thermal and cryodenervation) Ĭluster headache and other chronic headaches including migraines.Transection/avulsion of the occipital nerve.Surgical release of the lesser occipital nerve within the trapezius and other procedures to decompress occipital nerves.Resection or partial resection of the semispinalis capitus muscle.Resection or partial resection of muscle or tissue from the forehead, peri-orbital, occipital or other facial or scalp areas.Radiofrequency ablation (including the occipital nerve) / radiofrequency denervation / radiofrequency neurotomy.Pulsed radiofrequency ablation (see CPB 0735 - Pulsed Radiofrequency).Occipital nerve block (also known as occipital infiltration, and including greater occipital nerve block) ( Note: Occipital nerve block is allowable only for diagnosing occipital neuralgia).Neurolysis of the great occipital nerve with or without section of the inferior oblique muscle.Ligation of the supraorbital and supratrochlear arteries (for the treatment of migraines).Electrical stimulation of the occipital nerve (examples of devices for occipital nerve stimulation are ONSTIM and PRISM).Dorsal column stimulation (see CPB 0194 - Spinal Cord Stimulation).Decompression or microdecompression of the occipital nerves.Occipital neuralgia and other types of headache Radiofrequency denervation of cervical facet joints.Local injections of anesthetics or corticosteroids.Botulinum toxin (however, botulinum toxin is considered medically necessary for chronic migraine headache when criteria in CPB 0113 - Botulinum Toxin are met).This Clinical Policy Bulletin addresses invasive procedures for headaches.Īetna considers the following interventions experimental and investigational for the following headache types because the effectiveness of these approaches has not been established (not an all-inclusive list): Number: 0707 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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