CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Surgical Deactivation of Migraine Headache Trigger Sites

Defines coverage and medical necessity stance for surgical deactivation of migraine headache trigger sites for Blue Cross Blue Shield - Rhode Island across BlueCHiP for Medicare and Commercial products, including coding guidance and statements about evidence.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Surgical Deactivation of Migraine Headache Trigger Sites

Policy CodePolicy N/A

Change TypeRevised (no material clinical changes)

Effective DateOct 2, 2012

Next Review Date

Key ActionReport this service with an unlisted procedure code because there is no specific CPT or HCPCS code for surgical deactivation of migraine headache trigger sites.

SourceLink

POLICY UPDATE CHANGES

Not coveredBlueCHiP for Medicare stance

Not medically necessaryCommercial product stance

0Specific medical criteria defined

4CPT codes listed as not medically necessary if billed with migraine

Coverage Summary & Determination

This policy addresses surgical deactivation of migraine headache trigger sites for BlueCHiP for Medicare and Commercial products. For BlueCHiP for Medicare, surgical deactivation of migraine trigger sites is not covered because the evidence is insufficient to determine effects on health outcomes. For Commercial products, the procedure is considered not medically necessary for the same reason. Coding guidance notes no specific CPT/HCPCS code exists for the procedure and that certain listed CPT codes, when reported with a migraine diagnosis, will be considered not medically necessary.

Product-specific coverage stances and coding summary

BlueCHiP for Medicare stanceNot covered for Medicare

Commercial product stanceNot medically necessary for Commercial

Specific medical criteria defined0

CPT codes explicitly listed as not medically necessary if billed with migraine4

Coverage determination

Policy statements for different product lines:

BlueCHiP for Medicare: Surgical deactivation of migraine headache trigger sites is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products: Surgical deactivation of migraine headache trigger sites is considered not medically necessary. The evidence is insufficient to determine the effects of the technology on health outcomes.

Medical Necessity Criteria

Medical criteria section

Policy states 'Not applicable' for detailed medical necessity criteria

Medical Criteria: Not applicable (no specific medical-necessity criteria provided).

Coding Guidance

Unlisted procedure coding guidanceCPT

unlisted

No specific CPT or HCPCS code exists for surgical deactivation of migraine headache trigger sites; providers should report this service with an unlisted procedure code.

CPT codes considered not medically necessary when billed with migraine diagnosisCPTNot Covered

30520	Septoplasty or submucous resection, with or without cartilage scoring; contouring replacement with graft
30140	Submucous resection inferior turbinate, or complete, any method partial
64716	Neuroplasty and/or transposition; cranial nerve (specify)
67900	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Coding-related noncoverage if reported with migraine diagnosis

If any of the following CPT codes are reported and a diagnosis of migraine (ICD-10 G43.0*-G43.919) is present, the service will be considered not medically necessary:

CPT 30520 - Septoplasty or submucous resection, with or without cartilage scoring; contouring replacement with graft
CPT 30140 - Submucous resection inferior turbinate, or complete, any method partial
CPT 64716 - Neuroplasty and/or transposition; cranial nerve (specify)
CPT 67900 - Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

What Providers Must Do / Watch For

Billing Rule

Use unlisted procedure code

There is no specific CPT or HCPCS code for surgical deactivation of migraine headache trigger sites. Report this service using an appropriate unlisted procedure code.

Because there is no specific CPT or HCPCS code for surgical deactivation of migraine headache trigger sites, providers should report the service with an unlisted procedure code.

Denial Risk

Claim will be considered not medically necessary for listed CPTs with migraine diagnosis

If CPT codes 30520, 30140, 64716, or 67900 are billed with a diagnosis of migraine (ICD-10 G43.0*-G43.919), the service will be considered not medically necessary.

Affected CPTs: 30520, 30140, 64716, 67900

Background & Evidence Summary

Surgical deactivation targets identified migraine trigger sites (frontal, temporal, rhinogenic, occipital) by decompression or removal of trigeminal nerve branches and surrounding tissues (eg, removal of glabellar muscles, segmental nerve resection, septoplasty/turbinectomy, occipital muscle resection and interposition). The published evidence includes randomized controlled trials (three RCTs, only one sham-controlled and blinded) reporting improved outcomes at 12 months but with important limitations (patient selection, variability of procedures, and placebo effects). Because of these limitations and lack of evidence for non-migraine headaches, the evidence is insufficient to determine the effects of the technology on health outcomes.

Evidence highlights

Definitions & coding guidance

Policy Revision History

03/05/2020policy_updateLatest

Policy last updated on 03/05/2020; underlying coverage position remains that surgical deactivation of migraine headache trigger sites is not covered/not medically necessary due to insufficient evidence. Published in Provider Update, May 2020; document indicates multiple prior provider updates but states no clinical policy statement changes were identified.