CurrentBaylor Scott & White Health PlanPolicy 074

Occipital Nerve Stimulation

Defines Baylor Scott & White Health Plan coverage stance and medical necessity considerations for implanted occipital (peripheral) nerve stimulation devices for occipital neuralgia and headache disorders; applies to plan providers and claim reviewers governed by BSWHP benefit terms.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyOccipital Nerve Stimulation

Policy CodePolicy 074

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateMay 12, 2026

Key ActionVerify and obtain prior authorization when required and confirm benefit coverage in the member's Evidence of Coverage or Summary Plan Description.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Required in some instancesPrior auth

InvestigationalCommercial stance

ComprehensiveCode lists

All lines of businessApplies to

Coverage Determinations

General coverage stance

Policy coverage depends on plan type and applicable external guidance.

Medicare: For Medicare plans, refer to NCD 160.7 Electrical Nerve Stimulators; if NCD/LCD criteria exist, those take precedence.

Follow CMS NCD when applicable.

Medicaid: For Medicaid plans, confirm coverage per the Texas Medicaid Provider Procedures Manual (TMPPM); if TMPPM lacks guidance, use this policy's criteria.

TMPPM guidance prioritized for Medicaid.

Commercial/Other Plans: For all other plans, occipital nerve stimulation is considered investigational/experimental or unproven for intractable headache and therefore not supported by this policy absent plan-specific benefits.

Benefit plan document may override this policy.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyOccipital Nerve Stimulation

Policy CodePolicy 074

Change TypeNo material changes

Effective DateJun 1, 2025

Next Review DateMay 12, 2026

Key ActionVerify and obtain prior authorization when required and confirm benefit coverage in the member's Evidence of Coverage or Summary Plan Description.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Billing Codes

CPT CodesCPT

61885	Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
61886	Insertion or replacement of cranial neurostimulator pulse generator or receiver; with connection to 2 or more electrode arrays
61888	Revision or removal of cranial neurostimulator pulse generator or receiver
64553	Percutaneous implantation of neurostimulator electrodes; cranial nerve
64555	Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)
64568	Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64569	Revision or replacement of cranial nerve (eg vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
64575	Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling
64595	Revision or removal of peripheral or gastric neurostimulator pulse generator or

ICD-10 CodesICD-10

G43.xxx	Migraine
G44.0xx	Cluster headaches and other trigeminal autonomic cephalgias
G44.1	Vascular headache
G44.2xx	Tension-type headache
G44.5x	Complicated headache syndromes
R51	Headache

HCPCS / C / L codesHCPCS

C1767	Generator neurostimulator (implantable) non-rechargeable
C1778	Lead, neurostimulator
C1787	Patient programmer, neurostimulator
C1816	Receiver and/or transmitter neurostimulator (implantable)
C1820	Generator, neurostimulator (implantable), non-high frequency with rechargeable battery and charging system
C1822	Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
C1897	Lead neurostimulator test kit (implantable)
L8679	Implantable neurostimulator, pulse generator any type
L8680	Implantable neurostimulator electrode, each
L8681	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

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Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required — verify prior authorization (PA) requirements against the member's specific plan and any prior communications before scheduling or performing occipital nerve stimulation. Some lines of business (including certain Medicare or Medicaid arrangements) may follow federal or state coverage rules that affect PA needs.

Confirm PA via the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD).
Follow prior communications from the plan or delegated vendor regarding PA processes and forms.

Note

Conservative Treatment Expectation

Conservative treatments are expected to have been tried and documented before considering occipital nerve stimulation. Conservative therapies include pharmacologic management (analgesics, neuropathic agents), targeted injections (local anesthetic and steroid), and other noninvasive pain-management strategies. Surgical options to decompress or ablate the occipital nerve are considered more invasive alternatives when conservative measures fail.

Document prior trials of medications and response.
Document trials of injection therapy (anesthetic and/or steroid) and clinical response.

Documentation Required

Benefit Verification and Medical Necessity Documentation

Providers must verify member benefits and document medical necessity in the medical record. Review the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) for benefit limitations, exclusions, and coverage conditions. Medical necessity documentation should include diagnosis, prior conservative therapies tried, response to those therapies, and rationale for considering occipital nerve stimulation.

Include objective findings, prior treatment dates, and outcomes in submitted documentation.
Attach relevant prior authorization forms, operative notes, and consultation notes when required.

Denial Risk

Investigational for Most Commercial Plans

Occipital nerve stimulation is considered investigational/experimental or unproven for most commercial plans and non‑Medicare/Medicaid lines of business. Confirm coverage applicability for Medicare (see NCD 160.7) and Medicaid (follow applicable state TMPPM guidance); when no applicable federal or state mandate exists, the modality is generally not covered.

Medicare: check NCD 160.7 and any applicable LCDs for coverage criteria.
Medicaid: confirm state TMPPM guidance; if none, this medical policy applies.
Commercial plans: typically investigational — obtain PA and benefits confirmation before proceeding.

Conservative Therapy Expectations

Conservative treatment requirement

Covered when conservative (nonsurgical) therapies have been tried and failed prior to proceeding to invasive surgical interventions; the policy does not specify exact durations or number of trials.

Conservative therapies tried: Patient has undergone conservative treatments such as analgesics and other pharmacologic therapies, with or without adjunctive injections of local anesthetic and corticosteroid directed at the occipital region.

Conservative treatments include medications and injections as described in policy.

Failure of conservative therapy: Symptoms and functional impairment persist despite conservative management and the treating clinician documents failure of these therapies prior to considering invasive surgical options such as implantation of an occipital peripheral nerve stimulator or surgical decompression/destructive procedures.

Policy implies but does not enumerate specific timeframes or a required number of trials before surgery.

Key Definitions

Occipital neuralgia (ON) — definition and characteristic symptoms

DefinitionOccipital neuralgia (ON) is a rare neurological disorder characterized by piercing, throbbing, or electric‑shock‑like pain in the upper neck, back of the head, and behind the ears, usually on one side of the head.

Typical pain patternPain typically begins in the neck and spreads upward; some individuals also experience pain in the scalp, forehead, and behind the eyes.

Anatomic correlationLocation of pain relates to the course of the greater and lesser occipital nerves extending from where the spinal cord meets the skull up to the scalp at the back of the head.

EtiologyON can result from irritation or injury of the occipital nerve, though in many cases the cause is unknown.

Conservative therapiesConservative treatment options include analgesics and other drugs and may be supplemented with injections of anesthetic and steroid to reduce inflammation and block pain transmission.

Surgical options and considerationsIf conservative treatments fail, patients may undergo decompression or destructive surgery of occipital nerve segments; these techniques are highly invasive and may not provide complete, long‑term relief.

Occipital nerve stimulation (ONS) — definition of implanted peripheral nerve stimulation

DefinitionOccipital nerve stimulation (ONS) is implanted peripheral nerve stimulation that delivers a small electrical charge to the occipital nerves via electrodes connected to a subcutaneously implanted pulse generator in an attempt to prevent or treat migraines, other headaches, or occipital neuralgia.

Device componentsThe system consists of a subcutaneously implanted pulse generator (chest wall or abdomen), extension leads tunneled to electrodes placed across one or both occipital nerves at the base of the skull.

Stimulation modesContinuous or intermittent stimulation may be used.

Clinical contextImplanted peripheral nerve stimulators have been used for refractory pain for many years and more recently proposed for craniofacial pain including occipital, supraorbital, and infraorbital stimulation.

Background and Clinical Context

Occipital nerve stimulation delivers a small electrical charge to the occipital nerves via an implanted system consisting of electrodes placed near one or both occipital nerves and a subcutaneously implanted pulse generator connected by leads. The device may provide continuous or intermittent stimulation and is proposed for patients with refractory occipital neuralgia or headache who have not responded to medications and other conservative measures. Although implanted peripheral nerve stimulators have been used for refractory pain for many years and stimulation techniques (occipital, supraorbital, infraorbital) are described in the literature, the policy emphasizes that ONS has not demonstrated proven benefit for intractable headache and that less invasive treatment options exist.

OpenPayer