ModifiedCignaPolicy 0063

Headache, Occipital, and/or Trigeminal Neuralgia Treatment

Customize your policy alerts

Sign up for Cigna Policy 0063 alerts

Get alerted when Policy 0063 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs coverage of ablative treatments, electrical stimulation, surgical procedures, and nerve blocks for adults with headache conditions, occipital neuralgia, or trigeminal neuralgia. Specified treatments are considered not medically necessary or not covered/reimbursable.

Policy Summary

PayerCigna

PolicyHeadache, Occipital, and/or Trigeminal Neuralgia Treatment

Policy CodePolicy 0063

Change TypeModified

Effective DateNov 1, 2026

Next Review DateJun 15, 2027

Key ActionReview requests for specified ablative treatments, electrical stimulation, surgical procedures, and cranial nerve blocks because they may be denied as not medically necessary or not covered.

SourceLink

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedCignaPolicy 0063

Headache, Occipital, and/or Trigeminal Neuralgia Treatment

Customize your policy alerts

Sign up for Cigna Policy 0063 alerts

Get alerted when Policy 0063 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCigna

PolicyHeadache, Occipital, and/or Trigeminal Neuralgia Treatment

Policy CodePolicy 0063

Change TypeModified

Effective DateNov 1, 2026

Next Review DateJun 15, 2027

SourceLink

POLICY UPDATE CHANGES

A policy statement for electrical stimulation of the supraorbital nerve was added during the focused review.

Policy statements for nerve root decompression and occipital nerve neurolysis were removed during the annual review.

Policy statements for cervical microdecompression surgery (Jho Procedure), discectomy, and spinal fusion were removed in an earlier focused review.

AdultsPatient population addressed

6Ablative, electrical stimulation, or surgical treatments listed as not medically necessary

4Cranial nerve block categories not covered or reimbursable

1New policy statement added for supraorbital nerve electrical stimulation

2Policy statements removed in the annual review

3Additional procedures removed in an earlier focused review

Coverage Criteria

Ablative, electrical stimulation, and surgical procedures

Each of the following is considered not medically necessary for the treatment of headache or occipital neuralgia.

Specified ablative, electrical stimulation, or surgical treatments: Electrical stimulation of the occipital and/or supraorbital nerve; ganglionectomy; neurectomy; pulsed radiofrequency ablation; resection of the semispinalis capitis muscle; or topical anesthesia of the sphenopalatine ganglion.

Each listed treatment is considered not medically necessary.

Cranial nerve blocks

Each of the following nerve blocks is not covered or reimbursable for the treatment of headache, occipital neuralgia, and trigeminal neuralgia.

Specified nerve blocks: Occipital nerve block (CPT 64405); trigeminal nerve block (CPT 64400); sphenopalatine ganglion block (CPT 64505); or peripheral nerve blocks of other cranial nerves, such as the lesser occipital nerve (CPT 64450).

Each listed nerve block is not covered or reimbursable.

Electrical stimulation, ablation, and surgical procedures

The following codes are considered not medically necessary when used for ablative treatment, electrical stimulation, or surgical procedures for headache or occipital neuralgia.

Excluded neurostimulation or surgical uses: CPT codes 64553, 64555, 64568, 64575, 64590, 64999, or Category III code 1057T.

Code 64999 includes ganglionectomy, neurectomy, pulsed radiofrequency ablation, semispinalis capitis muscle resection, or topical anesthesia of the sphenopalatine ganglion for these conditions.

Cranial nerve blocks

The following cranial nerve blocks are not covered or reimbursable for treatment of headaches, occipital neuralgia, or trigeminal neuralgia.

Cranial nerve blocks: Occipital nerve blocks, trigeminal nerve blocks, sphenopalatine ganglion blocks, or peripheral nerve blocks of other cranial nerves, including the lesser occipital nerve, reported with CPT 64400, 64405, 64450, or 64505.

Insufficient evidence for nerve stimulation

Evidence does not establish durable clinical effectiveness or an acceptable safety profile.

Evidence limitations for occipital or supraorbital nerve stimulation: Available evidence consists largely of small, selected, observational, or methodologically limited studies; randomized trials show modest or inconsistent benefit, durability is uncertain, and device-related complications are substantial.

Combined supraorbital and occipital stimulation lacks randomized controlled trials, sham-controlled trials, prospective comparative studies, and systematic reviews in the cited evidence.

Occipital nerve stimulation evidence limitations

Evidence for occipital nerve stimulation remains limited.

Low evidence base: The Congress of Neurological Surgeons reports that evidence for occipital nerve stimulation remains low because of limited high-quality controlled trials, lack of dedicated commercially available craniofacial peripheral nerve stimulation devices, and limited trials specifically evaluating craniofacial neuromodulation.

The CNS recommendation is Level III.

Ganglionectomy evidence limitations

Available evidence is insufficient to establish the safety, effectiveness, or sustained clinical benefit of ganglionectomy.

Insufficient evidence: Available evidence for ganglionectomy consists primarily of small, uncontrolled, retrospective case series and low-level systematic reviews with inconsistent durability, frequent recurrence, incomplete complication reporting, and substantial risk of bias.

No professional society guidelines or consensus recommendations support ganglionectomy for headache disorders or occipital neuralgia.

Neurectomy evidence limitations

Evidence for neurectomy is limited and insufficient to establish safe or durable clinical benefit.

Insufficient evidence: Evidence for neurectomy is limited, low quality, and dominated by noncomparative studies with small populations, heterogeneous techniques, inconsistent outcomes, short or variable follow-up, and incompletely reported adverse events.

No major headache, neurology, pain management, or neurosurgical professional society has endorsed neurectomy for headache disorders or occipital neuralgia.

Migraine peripheral or occipital nerve blocks

Professional society and organizational guidance does not support routine use as medically necessary treatment for migraine.

Migraine nerve block medical necessity concern: Peripheral or occipital nerve blocks are not supported as medically necessary routine treatment for migraine because guidance either does not address them or cites very low-quality evidence, small studies, and heterogeneous techniques.

The policy does not provide a broader authorization pathway or alternative clinical criteria.

For headache disorders, including chronic migraine, chronic cluster headache, and cervicogenic headache, or for occipital neuralgia, electrical stimulation of the occipital and/or supraorbital nerve, ganglionectomy, neurectomy, pulsed radiofrequency ablation, semispinalis capitis muscle resection, and topical sphenopalatine ganglion anesthesia are considered not medically necessary.

Occipital nerve blocks, trigeminal nerve blocks, sphenopalatine ganglion blocks, and peripheral blocks of other cranial nerves, such as the lesser occipital nerve, are not covered or reimbursable when used to treat headache, occipital neuralgia, or trigeminal neuralgia.

The additional coding section identifies CPT 64400 for trigeminal nerve injections, 64405 for greater occipital nerve injections, 64450 for injections of other peripheral nerves or branches, and 64505 for sphenopalatine ganglion injection as not covered or reimbursable for headaches, occipital neuralgia, or trigeminal neuralgia.

The policy considers the specified ablative treatments, electrical stimulation, and surgical procedures not medically necessary for headache or occipital neuralgia. The procedures include occipital and/or supraorbital nerve stimulation, ganglionectomy, neurectomy, pulsed radiofrequency ablation, resection of the semispinalis capitis muscle, and topical anesthesia of the sphenopalatine ganglion.

When used for ablative treatment, electrical stimulation, or surgical treatment of headache or occipital neuralgia, CPT 64553, 64555, 64568, 64575, 64590, 64999, and Category III code 1057T are considered not medically necessary. Code 64999 also applies when reporting ganglionectomy, neurectomy, pulsed radiofrequency ablation, semispinalis capitis muscle resection, or topical sphenopalatine ganglion anesthesia for these conditions.

Evidence for occipital and/or supraorbital nerve stimulation is limited, heterogeneous, and largely low to moderate quality. Randomized studies show modest or inconsistent benefit, durability remains uncertain, and device-related complications—including lead migration, infection, hardware problems, reoperation, and device removal—are substantial. The cited chronic cluster headache study reported at least a 50% reduction in mean attack frequency in 44.6% of participants at 24 weeks and 50% at 48 weeks, with 59 serious adverse events reported.

Although some studies report reductions in pain intensity or medication use after peripheral or occipital nerve blocks for migraine, the evidence is limited by heterogeneous treatment parameters, small study populations, and short follow-up. Professional-society and organizational guidance therefore does not support these blocks as medically necessary routine treatment for migraine.

Coding and Diagnosis Information

Nerve blocks not covered or reimbursableCPTNot Covered

64405	Occipital nerve block
64400	Trigeminal nerve block
64505	Sphenopalatine ganglion block
64450	Peripheral nerve blocks of other cranial nerves (e.g., lesser occipital)

CPT and Category III codes considered not medically necessaryCPTNot Covered

64553	Percutaneous implantation of neurostimulator electrode array; cranial nerve
64555	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
64568	Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64575	Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver
64999	Unlisted procedure, nervous system
1057T	Insertion or replacement of subcutaneous neurostimulator pulse generators, with tunneling of 4 electrode arrays, bilateral supraorbital and occipital nerves, including all interrogation, programming, and imaging guidance, when performed

HCPCS neurostimulator supply and device codesHCPCSNot Covered

C1820	Generator, neurostimulator (implantable), with rechargeable battery and charging system
C1822	Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
L8679	Implantable neurostimulator, pulse generator, any type
L8680	Implantable neurostimulator electrode, each
L8682	Implantable neurostimulator radiofrequency receiver
L8683	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686	Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
L8687	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688	Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

CPT codes for cranial nerve blocks not covered or reimbursableCPTNot Covered

64400	Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve
64450	Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch
64505	Injection, anesthetic agent; sphenopalatine ganglion

ICD-10 diagnosis codesICD-10

B02.22	Postherpetic trigeminal neuralgia
G43.001	Migraine without aura, not intractable, with status migrainosus
G43.009	Migraine without aura, not intractable, without status migrainosus
G43.011	Migraine without aura, intractable, with status migrainosus
G43.019	Migraine without aura, intractable, without status migrainosus
G43.101	Migraine with aura, not intractable, with status migrainosus
G43.109	Migraine with aura, not intractable, without status migrainosus
G43.111	Migraine with aura, intractable, with status migrainosus
G43.119	Migraine with aura, intractable, without status migrainosus
G43.401	Hemiplegic migraine, not intractable, with status migrainosus

1–10 of 104

1/11

Chronic cluster headache study eligibility

Attack frequencyAt least 4 chronic cluster headache attacks per week

Minimum age18 years or older

Prior treatment responseNon-response, intolerance, or contraindication to verapamil and lithium, and to methysergide, topiramate, or gabapentin

ONS randomized treatment period

Study design24-week randomized, double-blind ONS treatment period

Intervention goal

Provider and Claims Guidance

Documentation Required

Prior Conservative and Interventional Treatment

Before considering occipital nerve stimulation (ONS) or neurectomy for refractory headache or occipital neuralgia, document failure of nonoperative and interventional treatment options. Neurectomy is generally reserved for patients who have failed these treatments and causes permanent sensory loss in the affected nerve distribution.

Document prior conservative therapies, such as pharmacologic treatment and physiotherapy.
Document prior interventional treatment, such as denervation, when applicable.
For neurectomy, document the refractory condition and failure of nonoperative and interventional alternatives.

Documentation Required

ONS Evaluation and Block Response

ONS consideration requires documentation of medically intractable symptoms, a positive psychological evaluation, and a positive response to a preliminary occipital nerve block. These requirements are described in the policy evidence review and should be included in the clinical record when ONS is evaluated.

Document a positive psychological evaluation before implantation.

Clinical Background

This policy addresses treatment of headache disorders, including chronic migraine, chronic cluster headache, and cervicogenic headache, as well as occipital neuralgia and trigeminal neuralgia. It distinguishes procedures considered not medically necessary from nerve blocks that are not covered or reimbursable for the conditions addressed.

Definitions

Occipital neuralgia

ConditionA cranial neuropathy

Pain patternUnilateral or bilateral, paroxysmal, sharp, shooting pain

Nerve distributionAlong the pathway of the greater, lesser, and/or third occipital nerves

Peripheral nerve field stimulation

Electrode placementAn electrode is placed subcutaneously near the site of maximum pain rather than directly at the nerve

System componentThe electrode is used together with a pulse generator

Alternative names

Prior Treatment Requirements

Not Covered Services

The policy identifies the following services as not covered or not medically necessary for the applicable headache conditions: electrical stimulation of the occipital and/or supraorbital nerve, ganglionectomy, and neurectomy. The same section also identifies pulsed radiofrequency ablation, semispinalis capitis muscle resection, and topical sphenopalatine ganglion anesthesia as not medically necessary.

Policy Summary

PayerCigna

PolicyHeadache, Occipital, and/or Trigeminal Neuralgia Treatment

Policy CodePolicy 0063

Change TypeModified

Effective DateNov 1, 2026

Next Review DateJun 15, 2027

SourceLink

On This Page

Comparator goal30% stimulation

ONS response rate

Response thresholdAt least 50% reduction in mean attack frequency

24-week response rate44.6% of participants

48-week response rate50% of participants

Document a positive response to a preliminary occipital nerve block.

Do not interpret a preliminary block response as establishing coverage for the block itself; applicable cranial nerve blocks may be not covered or reimbursable.

Denial Risk

Specified Headache and Occipital Neuralgia Procedures

The following ablative treatments, electrical stimulation procedures, and surgical procedures are considered not medically necessary when used to treat headache, including chronic migraine, chronic cluster or cervicogenic headache, or occipital neuralgia.

Electrical stimulation of the occipital and/or supraorbital nerve.
Ganglionectomy.
Neurectomy.
Pulsed radiofrequency ablation.
Resection of the semispinalis capitis muscle.
Topical anesthesia of the sphenopalatine ganglion.

Denial Risk

Cranial Nerve Blocks May Be Denied

Cranial nerve blocks are not covered or reimbursable for treatment of headache, occipital neuralgia, or trigeminal neuralgia.

Occipital nerve block (CPT 64405).
Trigeminal nerve block (CPT 64400).
Sphenopalatine ganglion block (CPT 64505).
Peripheral nerve blocks of other cranial nerves, such as the lesser occipital nerve (CPT 64450).

Billing Rule

Neurostimulation and Ablative Procedure Claim Denials

Claims may be considered not medically necessary when these codes are used to report ablative treatment, electrical stimulation, or surgical procedures for headache or occipital neuralgia. Code lists may not be all-inclusive, and deleted or inactive codes may not be eligible for reimbursement on the date of service.

CPT 64553, 64555, 64568, 64575, 64590, 64999, and Category III code 1057T.
CPT 64999 may be subject to the policy note when reporting ganglionectomy, neurectomy, pulsed radiofrequency ablation, semispinalis capitis muscle resection, or topical sphenopalatine ganglion anesthesia.
Verify current AMA and CMS code status and the code’s effectiveness on the date rendered.

Denial Risk

Cranial Nerve Block Services Not Reimbursable

The following HCPCS codes are not covered or reimbursable when used to report occipital, trigeminal, sphenopalatine ganglion, or other cranial peripheral nerve blocks for headache, occipital neuralgia, or trigeminal neuralgia.

C1820, C1822, L8679, L8680, L8682, L8683, L8685, L8686, L8687, and L8688.
Apply the denial condition when the related service is a cranial nerve block, including an occipital, trigeminal, sphenopalatine ganglion, or lesser occipital block.

Denial Risk

Insufficient Evidence for Peripheral Nerve Stimulation

Peripheral, occipital, and supraorbital nerve stimulation is not supported by sufficient evidence to establish durable clinical effectiveness or an acceptable safety profile for headache or occipital neuralgia. FDA clearance has not been granted for any occipital or supraorbital nerve stimulation device for these indications.

Evidence is limited, heterogeneous, and generally low to moderate quality, with modest or inconsistent benefit.
Combined supraorbital and occipital stimulation lacks randomized, sham-controlled, or prospective comparative trials.
Reported complications include lead migration, infection, allodynia, hardware problems, reoperation, explantation, and hospitalization.

Denial Risk

Insufficient Evidence for Neurectomy

The evidence for neurectomy, including C2 neurectomy, in headache disorders or occipital neuralgia is limited and insufficient to establish safe, durable clinical benefit. Published studies are primarily uncontrolled case reports and retrospective series, and no major headache, neurology, pain, or neurosurgical society endorses the procedure for these indications.

Studies have small samples, heterogeneous techniques, inconsistent outcomes, short or variable follow-up, and incomplete adverse-event reporting.
Potential harms include permanent sensory disturbance, bothersome numbness or hypersensitivity, and neuroma-related complications.
No randomized controlled trials establish comparative effectiveness for neurectomy.

Denial Risk

Insufficient Evidence for Pulsed Radiofrequency Ablation

Evidence supporting pulsed radiofrequency ablation (PRF) for headache or occipital neuralgia is limited, heterogeneous, and insufficient to demonstrate durable benefit or an acceptable safety profile. The VA/DoD 2023 guideline found insufficient evidence to recommend for or against PRF.

Studies have small samples, inconsistent techniques and outcomes, nonrandomized designs, and short-term follow-up, with benefits often not sustained.
Reported adverse events include sensory disturbances, worsening headache, weakness, dizziness, infection, bleeding, and rare serious neurologic complications.
No other major professional society has published guidance endorsing PRF for these indications.

Denial Risk

Semispinalis Capitis Muscle Resection Unsupported

Resection of the semispinalis capitis muscle is not supported by contemporary peer-reviewed evidence or professional society guidance for chronic headache disorders or occipital neuralgia. Studies of heterogeneous occipital trigger-site surgery combine multiple interventions, so outcomes cannot be attributed to this muscle resection.

Reported trigger-site procedures may combine nerve decompression, fascial release, vascular manipulation, neurectomy, and/or muscle resection.
No current major headache, neurology, pain, or neurosurgical society endorses semispinalis capitis muscle resection.

Denial Risk

Insufficient Evidence for Topical SPG Anesthesia

Evidence is insufficient to support topical anesthesia of the sphenopalatine ganglion for headache treatment. Professional guidance does not support SPG interventions for headache because the evidence is low quality and insufficient.

Studies consist primarily of case series and small randomized trials with short follow-up, conflicting results, and limited comparison with established treatments.
FDA device classification or exemption from premarket review does not establish clinical effectiveness or coverage.
Use may also be limited by nasal or facial conditions, bleeding disorders, severe respiratory distress, neoplasm, congestion with concerning symptoms, or nasal/facial fracture.

Denial Risk

Insufficient Support for Routine Migraine Nerve Blocks

Routine nerve blocks for migraine, other headache types, trigeminal neuralgia, or occipital neuralgia lack sufficient evidence to establish durable effectiveness, optimal treatment parameters, or clear comparative value. Professional guidance does not support peripheral or occipital nerve blocks as medically necessary routine treatment for migraine.

Evidence is characterized by small populations, heterogeneous techniques, short follow-up, attrition, subjective outcomes, and frequent confounding from preventive medications.
Systematic reviews report low or very low certainty because of methodological limitations, including pooling heterogeneous randomized and nonrandomized studies.
Short-term improvement in some studies does not establish durable benefit or justify routine use; applicable cranial nerve block codes remain not covered or reimbursable under the policy.

Subcutaneous target stimulation or peripheral nerve field stimulation

Omega or Reed Procedure

Procedure typeA proposed nerve stimulation procedure for chronic migraine

Stimulation targetsThe occipital, supraorbital, and/or peripheral nerves

Alternative nameThe Reed Procedure

Class I evidence

Evidence designAt least one well-designed randomized controlled clinical trial

Evidence scopeMay include an overview of randomized controlled clinical trials

Recommendation levelLevel I

Class II evidence

Evidence designAt least one well-designed comparative clinical study

ExamplesNonrandomized cohort studies, case-control studies, and other comparable studies

Additional evidenceMay include less well-designed randomized controlled trials

Class III evidence

Evidence sourcesCase series, comparative studies with historical controls, case reports, or expert opinion

Controlled trialsSignificantly flawed controlled trials are included

Recommendation levelLevel III

Neurectomy

ProcedureSurgical resection of an affected nerve

Intended purposeTo eliminate sensory input believed to contribute to pain generation

Key consequenceAssociated with permanent sensory loss in the nerve distribution

Ganglionectomy

ProcedureExcision or intentional destruction of an autonomic or sensory nerve ganglion

Intended purposeTo interrupt nociceptive signaling pathways

Potential targetsThe C2 and/or C3 ganglia

Pulsed radiofrequency ablation

TechniqueA non-neurodestructive radiofrequency technique

Energy deliveryShort bursts of energy rather than continuous current

Tissue effectAllows the needle to remain cool and reduces intended tissue destruction

Semispinalis capitis muscle resection

ProcedurePartial removal or sectioning of the semispinalis capitis muscle

Anatomic locationThe upper-neck muscle around the greater occipital nerve

Intended purposeTo relieve potential nerve entrapment or chronic irritation

Topical sphenopalatine ganglion anesthesia

Application siteAnesthetic is applied to the mucosa overlying the sphenopalatine ganglion

Common methodsA cotton pledget, catheter, or intranasal applicator may be used

Anatomic contextThe sphenopalatine ganglion is located behind mucosa posterior to the bony structures of the nose