Obtain authorization for listed HCPCS drug administration codes

Certain HCPCS drug administration codes listed in the policy (for example, J1110 dihydroergotamine, J3475 magnesium sulfate, J0706 caffeine citrate, J3032 eptinezumab, and J1885 ketorolac) are identified as covered if selection criteria are met and should be authorized per payer rules when applicable.

• Examples of HCPCS codes: J1110, J3475, J0706, J3032, J1885

Confirm prior authorization for CPT 64483 / 64484

Verify payer prior-authorization requirements for interventional procedure CPT codes listed in the policy (notably 64483 and 64484) before scheduling or billing.

• Codes specifically listed: 64483 (transforaminal epidural, single level) and 64484 (each additional level)

Document prescription/authorization and age for Cefaly

Cefaly (supraorbital transcutaneous stimulator) is FDA-authorized for migraine prevention in adults and should be prescribed and documented as a preventive device (daily use, 20 minutes) with patient age ≥18 noted in authorization materials.

• Device indicated for patients 18 years and older
• Use once daily for 20 minutes
• FDA cleared via de-novo pathway based on a 67-subject trial

Expect prior authorization for occipital nerve stimulation (ONS)

Occipital nerve stimulation (ONS) is an implantable therapy for medically intractable chronic migraine and prior authorization is expected; requests should document medically intractable status (e.g., ≥15 headache days/month), trials of medical therapy, and objective diary data supporting refractoriness as used in trials.

• ONS studied in randomized/feasibility trials with responder definitions (≥50% reduction or ≥3‑point pain decrease)
• Document chronicity (≥15 days/month) and prior treatment failures

Consider coverage and document trial period for gammaCore

Payers are encouraged to consider coverage of non-invasive vagal nerve stimulation (gammaCore) for episodic cluster headache as an acute option, with expectations for follow-up and stopping treatment if symptoms do not improve within the recommended trial period (e.g., 3 months per NICE guidance).

• Panel recommended gammaCore as a first-line acute option for eCH
• NICE recommends stopping gammaCore if symptoms do not reduce in first 3 months

Support anti‑CGRP mAb requests with baseline frequency and prior therapy history

Prior authorization requests for anti-CGRP monoclonal antibodies (for example erenumab dosing studied at 70 mg and 140 mg) should include baseline monthly migraine days and prior preventive therapy history, since randomized trials demonstrated reductions in monthly migraine days and increased responder rates versus placebo.

• Document baseline monthly migraine days
• Document prior preventive therapy trials and prior responses

Authorize multi‑day inpatient ketamine/lidocaine infusions with justification

Prior authorization may be required for inpatient multi-day continuous ketamine or lidocaine infusions for refractory chronic migraine; documentation should justify refractory status and prior treatment failures given limited and low-quality evidence.

• Justify inpatient admission and refractory chronic migraine diagnosis
• Provide details of infusion regimen, concurrent meds, monitoring, and outcomes

Do not assume no prior authorization when background is silent — verify with payer

Background sections do not state explicit prior-authorization codes or mandates for some procedures; absence of explicit PA language in policy excerpts means providers should verify payer-specific requirements rather than assume authorization is not needed.

• Policy notes lack of standardized SPG protocols and variability in use
• Verify payer rules for SPG blocks and related procedures

Include REN regulatory indication and patient age in authorization requests

The REN (Nerivio) device is FDA-cleared for acute treatment of migraine and preventive use in persons 12 years and older; while the document summarizes regulatory clearance, it does not specify payer prior‑authorization rules — include the device's FDA indication and patient age in requests.

• FDA-cleared for acute treatment and preventive use in patients ≥12 years
• Include FDA indication and patient age when seeking coverage

Expect prior authorization (or exclusion) for investigational neuromodulation devices

Many neuromodulation devices continue to be considered experimental or investigational; prior authorization is likely required or coverage may be excluded — provide detailed documentation of diagnosis, prior therapies, and rationale when seeking approval.

• Devices often labeled investigational and not covered by conventional plans
• Provide detailed clinical rationale and prior-treatment documentation

Provide comprehensive evidence and prior‑therapy documentation for neuromodulation PA requests

Because payers have historically considered many neuromodulation devices investigational, prior authorization is likely required and coverage decisions are variable; include objective diary data and prior-treatment failures in submissions.

• Document prior therapies tried and objective outcome measures
• Cite randomized trial evidence for REN where available (e.g., 2‑hour pain freedom)

Cite REN RCT evidence and preventive trial data in coverage requests

Coverage decisions for REN may consider randomized controlled trial evidence demonstrating acute 2‑hour pain freedom benefit and preventive trial results; when requesting coverage, include RCT outcomes and note limitations of real‑world long‑term datasets.

• Pivotal REN trial: 2‑hour pain-free 37.4% active vs 18.4% sham
• Preventive trial (Tepper 2023) showed mean reduction in migraine days (therapeutic gain 2.7 days)

Seek PA for neuromodulation or RFA with documentation of refractory status and prior therapies

When proposing high‑cost neuromodulation (ONS, DBS) or radiofrequency ablation (cervical medial branch RFA), prior authorization is appropriate and should document refractory status, prior therapies attempted, and objective outcome measures to justify intervention.

• ONS and DBS discussed as options for refractory conditions with pooled response rates cited
• Document prior failures of established acute and preventive therapies

Expect PA for novel neuromodulation devices (e.g., KOS) given limited evidence

Novel neuromodulation devices with limited evidence (for example Kinetic Oscillation Stimulation) may require prior authorization due to small single‑center trials; include study citations and rationale when requesting coverage.

• KOS pilot RCT (Juto & Hallin 2015) was small (n=36) and authors call for multicenter studies
• Provide objective measures and prior therapy history for consideration

No formal step‑therapy sequences stated — verify payer rules and document prior therapies

No explicit step therapy sequences are defined in the policy excerpts; do not assume formal required medication sequencing — document prior therapies tried when relevant, but confirm plan‑specific step‑therapy rules separately.

• Policy states no explicit step therapy sequences are defined
• Verify payer-specific step therapy or prior‑authorization requirements

Document prior outpatient trials and rationale when escalating to inpatient therapies

Clinical discussions describe escalation of care (for example, from outpatient care to multi‑day inpatient IV DHE or infusions) for refractory cases, but these are not formal step‑therapy mandates — document prior outpatient trials and reasons for escalation when requesting inpatient care.

• IV DHE multi‑day administration described for refractory or status migrainosus (>72 hours)
• Hospitalization may be necessary after outpatient maximal treatment fails

Document failure of standard therapies before proposing invasive modalities

For refractory chronic headache, guidance suggests considering more invasive modalities (such as neurostimulation) only after trials of specific drugs have failed; include documentation of failed standard therapies before escalation.

• Authors recommend addressing comorbidities and escalating to more invasive modalities as third‑line therapies
• Document trials of specific acute and preventive drugs

Prioritize guideline‑recommended agents and document trials before non‑supported options

Guideline reviews prioritize certain acute agents (e.g., prochlorperazine, specific triptans, NSAIDs) and discourage agents with low‑quality evidence, implying trial of guideline‑recommended pharmacologic therapies before less‑supported options; document such trials when relevant.

• Prochlorperazine and certain triptans have higher evidence grades
• Agents like propofol, IV lidocaine have limited/insufficient evidence per reviews

Try less‑invasive neuromodulation before invasive procedures and document trials

Non‑invasive neuromodulation techniques are generally recommended to be considered before more invasive neuromodulation modalities; when proposing invasive devices, document trials of less invasive options and safety/tolerability considerations.

• Non‑invasive options (nVNS, REN, tSNS, TMS) preferred before invasive techniques
• ONS and DBS reserved for refractory, difficult‑to‑treat patients

Document attempts or contraindications to less‑invasive neuromodulation before invasive options

Less invasive neuromodulation techniques (e.g., nVNS, transcranial stimulation, REN) are generally preferred to more invasive techniques (e.g., DBS); include documentation of attempts or contraindications to less invasive options when requesting invasive therapy.

• nVNS and SPG stimulation have at least one positive sham‑controlled trial for chronic cluster headache
• REN has randomized evidence for acute and preventive use

Document prior standard therapy failures before inpatient ketamine/lidocaine infusions

Ketamine or lidocaine infusions are often used after failure of other therapies (a stepwise escalation); when seeking authorization, document prior standard therapy attempts and rationale for infusion therapy per local payer expectations.

• Modified multi‑day inpatient infusion approaches are used for refractory chronic migraine after other treatments fail
• Standardized rCM diagnostic criteria are needed and documentation should reflect refractory status

Consider SPG/GON blocks after pharmacotherapy failure and document technique and prior trials

SPG and greater occipital nerve blocks are typically considered after failure of pharmacotherapies in refractory patients; although not formal step therapy rules, include prior pharmacotherapy trials and details of block technique and agents used in documentation.

• Tx360 studies used defined schedules (twice weekly for 6 weeks) and required baseline/follow‑up NRS measurements
• GONB meta‑analysis showed pooled pain‑free proportion at 1 month; document prior meds and response

Document REN use context (monotherapy vs adjunct) and prior medication history

When integrating REN into practice there is no mandated ordering relative to medications; consider patient characteristics and preferences and document whether REN is used as monotherapy or adjunctive therapy and prior medication history.

• Guidance suggests REN can be used as monotherapy or in combination for acute and preventive treatment
• Document device prescription, age, diagnosis (episodic vs chronic), and prior treatments

Policy does not define formal step‑therapy — verify payer‑specific rules

No specific step therapy or required medication trials are specified in the policy excerpts; providers should not infer mandated sequences from these background sections and must verify any payer-specific step therapy programs.

• Policy excerpts explicitly state no formal step therapy sequences
• Confirm insurer formularies and step‑therapy programs separately

Document pediatric REN rationale (age, school barriers) when requesting coverage

For pediatric REN use, authors suggest REN could be considered first‑line in school‑aged students due to barriers to medication administration at school; document age, school‑related barriers, and prior medication attempts when requesting coverage for pediatric patients.

• Studies and consensus suggest REN is a pragmatic option in school settings
• Document patient age and rationale for preferring non‑pharmacologic treatment

Document patient preference or intolerance when proposing REN over medications

REN may be offered as an alternative to pharmacotherapy for patients preferring nonpharmacologic approaches or with inadequate response/intolerance to medications; include patient preference and prior medication intolerance/nonresponse in documentation.

• American Headache Society consensus supports REN as option for patients preferring non‑pharmacologic approaches
• Include prior medication intolerance or inadequate response in records

Document trials or contraindications to standard ED agents before IV magnesium authorization

Insurers may require trials of standard ED agents (e.g., metoclopramide, prochlorperazine) or documentation of contraindication/intolerance before authorizing IV magnesium in ED/hospital settings; include prior ED treatments and contraindications in authorization requests.

• Practice advisory recommends IV magnesium 1–2 g over 15 minutes in appropriate patients without contraindications
• Document prior ED agent trials or contraindications to them

Document conservative therapy attempts prior to neuromodulation requests

Systematic reviews and guideline panels imply conservative and less‑invasive treatments are typically considered before neuromodulation; when requesting coverage for neuromodulation, include documentation of less‑invasive treatment attempts and rationale for escalation.

• Conservative therapies are typically tried before neuromodulation or RFA
• Include documentation of prior conservative therapy attempts and durations

Document trials of established therapies before seeking coverage for emerging interventions

Established acute and preventive therapies should be considered before emerging interventions (such as KOS or high‑dose vitamin regimens); include documentation of prior established therapies and objective symptom scores when seeking coverage for emerging treatments.

• KOS pilot data are small and authors call for larger trials
• Provide objective measures (e.g., MIDAS, pain scores) and prior therapy history

Document diagnosis and treatment setting consistent with covered indications

Ensure clinical indication documentation matches covered indications (for example, status migrainosus >72 hours, intractable severe migraine, cluster headache not responsive to oxygen/triptans) to support coverage of IV DHE, IV magnesium, caffeine infusion, eptinezumab, and related interventions.

• Status migrainosus defined as migraine lasting >72 hours
• Match ICD‑10 codes to covered indications per coding tables

Document procedure details and matching diagnosis codes for CPT 64483/64484

When billing or requesting authorization for procedures (e.g., transforaminal epidural codes 64483 and 64484), document the associated diagnosis codes and clinical justification consistent with the policy coding section to avoid coding‑based denials.

• CPT 64483 and 64484 listed in policy coding section
• Ensure ICD‑10 diagnosis supports the procedure per policy

Provide baseline and follow‑up NRS scores for Tx360/SPG blockade authorization

Clinical trials of SPG blockade (Tx360) required baseline headache measures and follow‑up numeric rating scale (NRS) scores at specified timepoints (pre‑treatment, 15 minutes, 30 minutes, 24 hours); include similar outcome documentation when justifying SPG procedures.

• Tx360 randomized trial measured NRS at baseline, 15, 30 minutes and 24 hours
• Include Headache Impact Test‑6 where available

Include headache diaries and responder definitions when supporting neuromodulation requests

For neuromodulation requests, include patient headache diaries and predefined responder definitions (for example, ≥50% reduction in headache days or ≥3‑point pain intensity reduction) as used in ONS trials to document benefit and refractoriness.

• ONS trials used headache diaries and responder definitions (≥50% reduction or ≥3‑point pain drop)
• Provide objective diary data covering baseline and follow‑up periods

Provide comprehensive documentation of selection, regimen, outcomes, and consent for neuromodulation

Document patient selection, treatment regimen, outcome measures (attack frequency, severity, medication use, quality of life), and informed consent acknowledging uncertainty of efficacy when seeking authorization for neuromodulation or novel devices.

• Document selection criteria, regimen, outcomes, device durability, and informed consent
• Track functional outcomes and adverse events

Document baseline migraine days and prior preventive therapy when requesting anti‑CGRP mAbs

Prior‑authorization requests for anti‑CGRP monoclonal antibodies should include prior treatment history and objective baseline migraine frequency (monthly migraine days) and prior responses since RCTs report changes in monthly migraine days and responder rates.

• Document baseline monthly migraine days and prior preventive therapy responses
• Cite randomized trial outcomes for erenumab as relevant

Supply comprehensive inpatient infusion documentation for ketamine/lidocaine

For inpatient lidocaine or ketamine infusions, provide documentation supporting the refractory diagnosis, prior treatment failures, indication for admission, infusion regimen details, monitoring plans, and observed outcomes (pain scores, length of stay).

• Retrospective cohorts reported effectiveness but high adverse‑event rates; include monitoring and risk mitigation plans
• Detail prior trials and rationale for inpatient infusion

Document specific technique, agents, and prior responses for nerve blocks and TPIs

Practice surveys show variability in nerve block and trigger‑point techniques; when requesting coverage, document indication, specific sites injected, agents used (eg, local anesthetic, corticosteroid), schedule/protocol, and prior response to other therapies to reduce documentation‑based denials.

• Surveys highlight variability in injection sites, agents, dosing, and schedules
• Provide precise procedural details and prior outcomes

Include trial outcome metrics and AE data when supporting device effectiveness claims

Document clinical trial outcomes and device tolerability data (for example, 2‑hour pain relief/pain‑free rates and adverse event rates) when claiming effectiveness for REN or other neuromodulation devices to support medical necessity.

• REN pivotal trial: 2‑hour pain relief 66.7% active vs 38.8% sham; pain‑free 37.4% vs 18.4%
• Report device‑related AE rates from trials and real‑world datasets

Include device/app symptom diaries (eg, Nerivio) and MIDAS in documentation

Capture patient symptom reporting collected via device apps (for REN, the Nerivio app records pre‑treatment and 2‑hour post‑treatment diaries); include such app‑derived diaries or MIDAS scores in authorization documentation when available.

• Nerivio app captures pre‑treatment and 2‑hour post‑treatment symptom reports
• Real‑world programs collected MIDAS scores and device utilization metrics

Provide MIDAS, prospective pain/disability reports, and device utilization as supporting documentation

Suggested supporting documentation to establish medical necessity includes MIDAS scores, prospective pain and disability reports, device utilization patterns, and objective pre/post treatment outcomes; include these where possible to strengthen authorization requests.

• MIDAS score changes and prospective 2‑hour outcomes support effectiveness
• Device utilization metrics (treatments per month) and adverse events help contextualize benefit and safety

Document pediatric/ED REN use details and app‑reported outcomes

When prescribing REN for pediatric patients or in ED settings, document device prescription, patient age, diagnosis (episodic vs chronic migraine), prior treatments tried, and whether REN is used alone or with medications, and record treatment sessions and patient‑reported outcomes via the device app.

• Orr et al pilot trial in pediatric ED used REN vs standard IV therapy; document feasibility and outcomes
• Record whether REN used as monotherapy or adjunct and track 2‑hour outcomes

Document timing and outcome measures when using REN adjunctively during procedures

Document REN use during procedures (for example, applied 10 minutes before BoNT‑A injections and continued during procedure) with recorded procedural pain scores and postprocedural headache incidence to support claims of procedural benefit.

• Mayo Clinic randomized crossover trial applied REN 10 minutes before and during BoNT‑A injections with significant pain reduction
• Record pre‑, intra‑, and post‑procedure VAS scores

Detail diagnosis, RFA technique, and follow‑up outcomes to reduce documentation‑based denials

Provide clear diagnostic criteria, prior conservative therapies attempted, the specific RFA technique (continuous vs pulsed, temperature, duration), and follow‑up outcomes when requesting coverage for RFA or related procedures to mitigate documentation risk due to heterogeneity in studies.

• Systematic reviews note variability in RFA technique and patient selection
• Include procedural parameters and follow‑up pain outcomes

Provide detailed prior therapies, dosing, and objective scores for KOS / vitamin requests

Include details of prior therapies, indication (acute vs prophylactic), specific device or supplement regimen, dosing (eg, thiamine 990 mg/day in cited trial), and objective symptom scores/timepoints when requesting coverage for KOS or vitamin regimens, given limited trial evidence.

• KOS pilot RCT small (n=36) and calls for multicenter studies
• Thiamine trial used 990 mg daily; document dosing and trial outcomes

Avoid billing not‑covered CPT/HCPCS/ICD‑10 codes to prevent denials

Use of CPT/HCPCS/ICD‑10 codes listed as 'not covered' (for example, cranio‑sacral therapy or intra‑oral splint codes) for CPB indications may trigger claim denials — do not bill those codes for covered claims.

• CPT/HCPCS codes for cranio‑sacral therapy and intra‑oral splints are listed as not covered
• Verify billing codes against the policy's not‑covered list before claim submission

Ensure diagnosis codes align with policy to avoid coding‑based denials

ICD‑10 diagnosis codes that are noted as not covered for CPB indications (for example G44.86 Cervicogenic headache and M54.2 Cervicalgia) may lead to coding‑based denials; ensure diagnosis coding aligns with covered indications in the policy.

• ICD‑10 codes listed as not covered include G44.86 and M54.2
• Map the procedure to an appropriate covered ICD‑10 when billing

Be aware CTAF evidence judgments can lead to non‑coverage — include robust evidence

Technology assessments that judged evidence inadequate for certain devices (for example CTAF findings for Cefaly and SpringTMS) may result in non‑coverage or denial if submissions rely on devices deemed inadequately supported; include higher‑quality evidence when available.

• CTAF voted evidence inadequate to show equivalence to standard care for some devices
• Provide controlled‑trial data and economic rationale where possible

Expect denial risk for therapies with limited evidence; provide strong justification and prior‑therapy documentation

Interventions with insufficient or low‑quality evidence (for example propofol, IV valproic acid, ketamine) face higher risk of denial; include compelling, case‑specific justification and comprehensive prior‑therapy documentation when requesting coverage for these therapies.

• Guideline reviews recommended against or found insufficient evidence for propofol and intranasal lidocaine
• IV valproic acid not proven effective and was inferior to prochlorperazine in one trial
• Ketamine trials are few, small, and at high risk of bias