CurrentKaiser PermanentePolicy N/A

Kaiser Foundation Health Plan of Washington Clinical Review Criteria

Kaiser Permanente Clinical Review Criteria addressing medical necessity and coverage stance for occipital nerve stimulation (ONS) and deep brain stimulation (DBS) for primary headache disorders (including migraine, cluster headache, cervicogenic headache) for Kaiser Foundation Health Plan of Washington members; distinguishes Medicare versus non-Medicare determinations and references external guidance (MCG and LCD).

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy CodePolicy N/A

Change TypeClarified (non-material)

Effective Date

Next Review Date

Key ActionVerify authorization requirements for a specific code by plan type using the Pre-authorization Code Check; Medicare members follow applicable LCD/LCA requirements.

SourceLink

POLICY UPDATE CHANGES

Adopted MCG A-0716 for non-Medicare determinations on 04/05/2016.

Non-MedicareNot covered (non-Medicare)

MedicareMay be covered (Medicare if LCD/LCA met)

LimitedEvidence strength

Coverage Summary

This document provides Kaiser Permanente Clinical Review Criteria for Occipital Nerve Stimulation (ONS) and Deep Brain Stimulation (DBS) for primary headache disorders (including migraine, cluster headache, and cervicogenic headache) and specifies medical necessity and coverage stance for Kaiser Foundation Health Plan of Washington members. The policy is CURRENT and distinguishes Medicare versus non‑Medicare determinations and references external guidance (MCG for non‑Medicare and LCD/LCA for Medicare).

Medicare members: coverage may be provided when applicable LCD/LCA and policy criteria are met. Non‑Medicare members: ONS is considered NOT MEDICALLY NECESSARY per MCG guidance. Evidence strength: limited/low‑quality evidence.

Medical‑Necessity Criteria

Medicare Coverage Determination

Considered medically necessary when criteria in the applicable policy statements listed above are met:

Applies to Medicare members

Medicare coverage follows applicable policy statements and LCD/LCA (Peripheral Nerve Stimulation L37360 and Billing and Coding A55531) as listed

Non-Medicare Coverage Determination (Kaiser WA)

Kaiser Permanente non-Medicare policy using MCG guidance:

Occipital Nerve Stimulation (ONS) is considered NOT MEDICALLY NECESSARY for treatment of primary headache disorders

Kaiser Permanente has elected to use the MCG Occipital Nerve Stimulation (A-0716) criteria; service is not covered per MCG guidelines

Evidence / Medical Technology Assessment Conclusion

MTAC evidence conclusion informing coverage:

Available literature is limited (small case series, case reports) and does not provide sufficient evidence to determine efficacy or safety of ONS or DBS for prevention or treatment of chronic primary headache

Supports non-coverage decision for non-Medicare members

ONS and DBS are not FDA-approved for treatment or prevention of primary headaches

Coding

Relevant CPT codes (procedures referenced)CPT

64555	Percutaneous implantation of neurostimulator electrode array, peripheral nerve (excludes sacral nerve)
64575	Incision for implantation of neurostimulator electrode array, peripheral nerve (excludes sacral nerve)
64585	Revision or removal of peripheral neurostimulator electrode array
64590	Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or
64595	Unspecified in source text (listed)

Relevant HCPCS / C-codes / L-codes (devices and supplies)HCPCS

C1767	Generator neurostimulator (implantable) nonrechargeable
C1778	Lead neurostimulator (implantable)
C1787	Patient programmer neurostimulator
C1816	Receiver and/or transmitter, neurostimulator (implantable)
C1820	Generator neurostimulator (implantable) with rechargeable battery and charging system
C1822	Generator neurostimulator (implantable) high frequency with rechargeable battery and charging system
C1823	Listed in document (no description provided)
C1883	Adaptor/extension pacing lead or neurostimulator lead (implantable)
C1897	Lead neurostimulator test kit (implantable)
L8679	Implantable neurostimulator pulse generator, any type

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Provider Actions

Prior Authorization

Verify authorization requirements

Verify authorization requirements for the specific code and plan type using the Pre-authorization Code Check. For Medicare members, follow the applicable LCD and Local Coverage Article requirements noted for Peripheral Nerve Stimulation (e.g., L37360 and A55531).

Affected codes: 64555, 64575, 64585, 64590, C1767, L8679

Documentation Required

MCG criteria availability and request

MCG Occipital Nerve Stimulation (A-0716) criteria are used for medical necessity determinations for non‑Medicare members. Providers may request a copy of the specific MCG criteria used for a utilization management decision by calling Kaiser Permanente Clinical Review staff or by accessing the MCG Guideline Index via the provider portal.

Applies to non‑Medicare members

Denial Risk

Non-Medicare coverage denial for ONS

For non‑Medicare members, occipital nerve stimulation (ONS) for primary headache disorders is considered not medically necessary per the MCG guideline and claims may be denied.

Affected procedure codes: 64555, 64575

Background

Primary headache disorders (including migraine, cluster headache, cervicogenic headache, occipital neuralgia and other primary headaches) are common and disabling; migraine affects about 15% of the population and transformed migraine is chronic (>15 days/month), while cluster headache can become chronic in 10–20% of patients and may be refractory to medical treatment. Cervicogenic headache typically begins in the suboccipital region with pain referred to trigeminal sensory fields and many ablative surgical procedures have inconsistent effects and carry serious complication risks.

Neurostimulation approaches for intractable primary headache disorders emerged in the early 2000s and build on prior spinal cord stimulation work. Two broad types are described: peripheral approaches targeting occipital nerve branches (Occipital Nerve Stimulation, ONS) and central approaches using Deep Brain Stimulation (DBS) such as posterior hypothalamic stimulation for chronic cluster headache.

ONS implantation is typically a three‑phase surgical procedure: phase 1—subcutaneous bilateral electrode implantation over the greater occipital nerve; phase 2—external stimulator testing with awake patient feedback as amplitude is increased (0 to ~4 V) to confirm paresthesia radiating ≥4 cm cephalad from skull base; phase 3—implantation of the pulse generator (pectoral/abdominal/gluteal) and connection via tunneled leads. Reported complications include lead migration, infection, localized pain, muscle spasm, and loss of effect.

DBS involves MRI‑guided stereotactic placement of one or more electrodes (e.g., posterior hypothalamus, thalamus, globus pallidus, subthalamic nucleus), often initially tested with temporary transcutaneous cables before permanent implantation and subsequent programmable noninvasive adjustments. DBS requires highly experienced neurosurgeons and carries risks including intracerebral hemorrhage and possible mortality; preoperative neuroimaging is required to exclude conditions increasing hemorrhagic risk. Neither ONS nor DBS are FDA‑approved for the treatment or prevention of primary headaches.

Definitions

ONSOccipital Nerve Stimulation, peripheral nerve stimulation targeting occipital nerve branches.

DBSDeep Brain Stimulation, stereotactic implantation of electrodes in deep brain structures (e.g., posterior hypothalamus) for headache treatment.

Evidence base: Mostly small case series and case reports; the MTAC review found around 15 small prospective and retrospective case series (3–25 patients) and multiple case reports, with no published randomized or nonrandomized controlled trials identified; overall the literature is limited and does not provide sufficient evidence to determine efficacy or safety of ONS or DBS for chronic primary headache.

Determination	ID / Type
Peripheral Nerve Stimulation	L37360 (LCD)
Billing and Coding: Peripheral Nerve Stimulation	A55531 (LCA)

Revision History

04/05/2016adoption

Adopted MCG A-0716 for non-Medicare determinations on 04/05/2016

10/05/2021codes_updated

10/05/2021: Updated applicable codes

2024-08-06review

08/06/2024 MPC review — no clinical policy statement changes

2025-08-05reviewLatest

08/05/2025 MPC review — no clinical policy statement changes