CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Sphenopalatine Ganglion Block Policy

Defines coverage position for sphenopalatine ganglion (SPG) nerve block procedures (intranasal catheter-based or otherwise) for treatment of migraines, cluster headaches, acute headaches and other indications across Commercial and Medicare Advantage products offered by Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySphenopalatine Ganglion Block Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2017

Next Review Date

Key ActionFile claims with CPT 64999 for SPG block procedures and note that CPT 64505 is not covered and may be denied.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy content.

Not coveredNot covered for all indications

64999Billing instruction: use unlisted code

64505Explicitly not covered CPT

Coverage Summary

Sphenopalatine ganglion (SPG) nerve blocks are procedures that apply topical local anesthetic to the mucosa overlying the SPG, most commonly via intranasal catheter devices (for example, Sphenocath, Allevio, Tx360) to attempt to treat chronic migraine, cluster headache and other severe headaches. The technique involves inserting an intranasal catheter and delivering local anesthetic (eg, lidocaine or bupivacaine) to the posterior nasal wall to reach the SPG.

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This policy defines the coverage position for SPG nerve block procedures (intranasal catheter-based or otherwise) across Blue Cross Blue Shield — Rhode Island products. The policy applies to Medicare Advantage and Commercial products and addresses use for migraines, cluster headaches, acute headaches and other indications. Claims for the procedure should be filed using CPT 64999 (Unlisted procedure, nervous system); CPT 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is explicitly not covered / not medically necessary for Medicare Advantage and Commercial products.

Medical-Necessity / Coverage Determinations

Medicare Advantage Coverage Determination

SPG blocks are not covered when the evidence is insufficient to determine health outcomes:

ALL of the following

Sphenopalatine ganglion blocks are not covered for all indications, including but not limited to the treatment of migraines and non-migraine headaches
Rationale: evidence is insufficient to determine the effects of the technology on health outcomes

Commercial Coverage Determination

SPG blocks are considered not medically necessary for all indications:

ALL of the following

Sphenopalatine ganglion blocks are considered not medically necessary for all indications, including but not limited to the treatment of migraines and non-migraine headaches
Rationale: evidence is insufficient to determine the effects of the technology on health outcomes

Prior Authorization

Policy-level prior authorization requirement:

ALL of the following

Prior authorization: Not applicable (no PA requirement specified in policy)

Provider Actions / Billing Guidance

Documentation Required

File claims with unlisted CPT when reporting SPG block

There is no specific CPT code for the SPG block; file claims using CPT 64999 (Unlisted procedure, nervous system).

64999

Denial Risk

Claims for CPT 64505 are not covered

CPT 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products — claims using this code may be denied.

64505 (may be denied)

Background, Evidence & Definitions

Evidence includes a limited number of randomized controlled trials and case series. One RCT in chronic migraine (a course of 12 treatments over 6 weeks) showed short-term benefits up to 24 hours but did not demonstrate significant longer-term effects at 1 and 6 months, and a separate RCT in the emergency setting found no significant difference at 15 minutes but a higher proportion headache-free at 24 hours. Case series for cluster headache reported variable results (some series reporting 40–50% complete symptom relief) and notable treatment-related complications (about 20% in some series).

Overall, the evidence is insufficient in quality and duration to determine meaningful, durable clinical benefit of SPG blocks for headache disorders.

Evidence type	Summary
Randomized controlled trials
1 RCT in chronic migraine (12 treatments over 6 weeks) showed short-term benefits up to 24 hours but not significant longer-term effects; 1 RCT in emergency setting (single block) showed no significant difference at 15 minutes but more patients were headache-free at 24 hours
Case series
Case series for cluster headache (small, variable methods) reported ~40–50% complete symptom relief in some series and ~20% treatment-related complication rate; evidence considered insufficient

Sphenopalatine ganglion (SPG) block: Topical application of local anesthetic to the mucosa overlying the SPG, commonly via intranasal catheter devices (eg, Sphenocath, Allevio, Tx360) to attempt to treat headache disorders.

Unlisted procedure code (64999): There is no specific CPT code for the SPG block; claims should be filed with CPT 64999 (Unlisted procedure, nervous system).

Not-covered CPT (64505): CPT 64505 (Injection, anesthetic agent; sphenopalatine ganglion) is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySphenopalatine Ganglion Block Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2017

Next Review Date

Key ActionFile claims with CPT 64999 for SPG block procedures and note that CPT 64505 is not covered and may be denied.

SourceLink

On This Page

OpenPayer

Sphenopalatine Ganglion Block Policy

Coverage Summary

Medical-Necessity / Coverage Determinations

Coding

Provider Actions / Billing Guidance

Background, Evidence & Definitions

Revision History