CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Sphenopalatine Ganglion Blocks for Migraines

Defines coverage position for sphenopalatine ganglion blocks (intranasal catheter or other SPG block techniques) for migraine and other headache indications for Medicare Advantage and commercial products, including coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySphenopalatine Ganglion Blocks for Migraines

Policy CodePolicy N/A

Change TypeClarified coding and coverage stance

Effective DateAug 1, 2017

Next Review Date

Key ActionClaims for SPG block procedures should be filed with CPT code 64999; claims billed with CPT 64505 may be denied as not covered/not medically necessary.

SourceLink

POLICY UPDATE CHANGES

Policy states SPG blocks are not covered/not medically necessary for headache indications due to insufficient evidence.

1RCTs chronic migraine

1RCTs emergency headache

0Covered indications

Coverage Summary

Defines coverage position for sphenopalatine ganglion (SPG) blocks (intranasal catheter or other SPG block techniques) for migraine and other headache indications for Medicare Advantage and commercial products. Background: SPG nerve blocks involve topical application of local anesthetic to the mucosa overlying the SPG, typically delivered via intranasal catheter, and have been proposed for chronic migraine and some severe non-migraine headaches. Evidence summary: small randomized controlled trials and case series report short-term benefits (for example, an RCT showing benefit up to 24 hours and an emergency-setting RCT with improvement at 15 minutes and more patients headache-free at 24 hours), but studies are underpowered for longer-term efficacy and safety and case series show variable relief with some complications. Policy stance: Not covered / Not medically necessary for all headache indications (Medicare Advantage: not covered; Commercial: not medically necessary). Effective date: 2017-08-01. Last review: 2023-08-16.

Medical Necessity / Coverage Determinations

Medicare Advantage Plans Coverage Determination

Sphenopalatine ganglion blocks are not covered for all headache indications when evidence is insufficient:

SPG blocks are not covered for all headache indications, including but not limited to treatment of migraines and non-migraine headaches

Rationale: evidence insufficient to determine effects on health outcomes

Commercial Products Coverage Determination

Sphenopalatine ganglion blocks are considered not medically necessary for headache indications when evidence is insufficient:

SPG blocks are considered not medically necessary for all headache indications, including but not limited to treatment of migraines and non-migraine headaches

Rationale: evidence insufficient to determine effects on health outcomes

Coding and Billing

Coding and Billing Guidance

Procedural coding instructions for claims submission:

There is no specific CPT/HCPCS code for SPG block procedures; file claims using unlisted procedure code 64999 (Unlisted procedure, nervous system)

Code 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products

Unlisted procedure code for claim filingCPT

64999

Unlisted procedure, nervous system

Not covered / Not medically necessary codesCPTNot Covered

64505

Injection, anesthetic agent; sphenopalatine ganglion

Provider Actions & Billing Impact

Billing Rule

Use unlisted CPT for SPG procedures

Claims for SPG block procedures should be filed with CPT code 64999 (Unlisted procedure, nervous system).

64999

Denial Risk

Claim denial for 64505

Claims billed with CPT code 64505 (Injection, anesthetic agent; sphenopalatine ganglion) are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products and may be denied.

64505
Applies to Medicare Advantage and Commercial products

Background & Evidence Summary

Background: Sphenopalatine ganglion (SPG) nerve blocks are a proposed treatment for chronic migraines and some severe non-migraine headaches. The SPG is a group of nerve cells located behind the structures of the nose linked to the trigeminal nerve. SPG blocks typically involve topical application of local anesthetic to the mucosa overlying the SPG, most commonly by inserting an intranasal catheter attached to a syringe delivering lidocaine or bupivacaine to the posterior nasal wall. Three catheter devices are commercially available in the U.S.; procedure details and frequency vary across devices and protocols. Evidence limitations: available studies include small RCTs and case series showing short-term benefit but insufficient longer-term efficacy and safety data. There is no specific procedure code; claims should be filed using unlisted procedure code 64999, and CPT code 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is listed as not covered / not medically necessary for these products.

Evidence Item	Summary
Chronic migraine RCTs
1 RCT: short-term benefit up to 24 hours after a 6-week course (12 treatments); no significant longer-term effects (1 and 6 months); underpowered for long-term efficacy.
Emergency setting RCT
1 RCT in emergency setting: statistically significant reduction at 15 minutes and more patients headache-free at 24 hours; overall evidence insufficient to determine effectiveness.
Cluster headache evidence
Case series (small): 40-50% complete relief for variable durations; ~20% had treatment-related complications; approaches differed from current intranasal device-based technique; evidence insufficient.
Coding guidance - unlisted code
There is no specific CPT code; claims should be filed with unlisted procedure code 64999 (Unlisted procedure, nervous system).
Coding guidance - 64505
CPT 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is not covered for Medicare Advantage and is not medically necessary for Commercial Products.

Definitions: Sphenopalatine ganglion (SPG) block — a procedure involving topical application of local anesthetic to the mucosa overlying the SPG, typically performed via an intranasal catheter to deliver agents (eg, lidocaine or bupivacaine) to the posterior nasal cavity with the intent to reduce headache symptoms.