CurrentKaiser PermanentePolicy N/A

Surgical Deactivation of Trigger Sites for Treatment of Migraine Headaches (Clinical Review Criteria)

Clinical review criteria for surgical treatment (deactivation of trigger sites) of migraine headaches for Kaiser Foundation Health Plan of Washington members and providers; describes medical necessity conclusions, documentation to submit, and lists CPT and ICD-10 codes considered not medically necessary.

Policy Summary

PayerKaiser Permanente

PolicySurgical Deactivation of Trigger Sites for Treatment of Migraine Headaches (Clinical Review Criteria)

Policy CodePolicy N/A

Change TypeNo material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen requesting review of surgical treatment for migraine, submit the most recent clinical note from the requesting provider and the last 2 years of neurology notes to support medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 RCTsRandomized controlled trials identified in evidence review

No active NCD/LCDCMS coverage guidance for Medicare members

MultipleCodes explicitly flagged

Medical Necessity Determination

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ALL of the following

Available evidence (two RCTs with methodological limitations and observational studies) suggests possible improvement in migraine frequency, intensity, and duration compared with controls, but safety, efficacy compared to standard therapy, and long-term efficacy are unknown or limited.
Surgical deactivation of trigger sites does not meet Kaiser Permanente Medical Technology Assessment Criteria.
Therefore surgical deactivation of trigger sites for treatment of migraine headaches is considered Not Medically Necessary (i.e., not covered).

Codes and Coverage Status

Considered Not Medically Necessary - CPT and procedure codesmixedNot Covered

15824	Rhytidectomy; forehead
15826	Rhytidectomy; glabellar (frown lines)
21299	Unlisted craniofacial and maxillofacial procedure
30520	Septoplasty or submucous resection, with or without cartilage scoring; contouring or replacement with graft
30801	Ablation, soft tissue of inferior turbinates, unilateral or bilateral, superficial
30802	Ablation, soft tissue of inferior turbinates, intramural (submucosal)
31200	Ethmoidectomy, intranasal, anterior
31201	Ethmoidectomy, intranasal, total
31205	Ethmoidectomy (code listed but description incomplete in source)
31254	Nasal/sinus endoscopy with ethmoidectomy; partial (anterior)

1–10 of 15

1/2

Considered Not Medically Necessary - ICD-10 diagnosis codesICD-10Not Covered

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
G43.409	Hemiplegic migraine

1–10 of 44

1/5

What Providers Must Do

Documentation Required

Submit supporting clinical documentation

When requesting review of surgical treatment for migraine, submit the most recent clinical note from the requesting provider and the last 2 years of neurology notes to support medical necessity review.

Most recent clinical note from requesting provider
Last 2 years of neurology notes

Prior Authorization

Pre-authorization Code Check

To verify authorization requirements for a specific code by plan type, use the Pre-authorization Code Check tool as noted in the policy.

Clinical and Evidence Context

Surgical deactivation of migraine trigger sites originated after clinicians observed that certain cosmetic facial procedures unexpectedly relieved migraine symptoms in some patients. The initial step in evaluating candidates is trigger site identification, which is commonly performed using botulinum toxin (Botox) injections or local nerve blocks. In the literature, patients who experience either complete elimination of headaches or at least a 50% improvement in headache frequency and/or intensity after these diagnostic injections have been considered potential surgical candidates.

The specific operative approach depends on the anatomical trigger site. Procedures described in the literature include focal removal or modification of facial muscles, transection or avulsion of peripheral sensory nerves, and surgical modification of sinonasal structures. Surgical technique therefore varies by site and may involve muscle removal, nerve transection, or sinus-related procedures.

Available evidence includes multiple observational studies and two randomized controlled trials (RCTs) (with a follow-up study reported for one trial), all conducted by the same investigator. The RCTs and observational data suggest that surgical deactivation may reduce migraine frequency, intensity, and duration and increase the proportion of patients achieving complete elimination compared with control (nonoperative or sham) groups. However, the trials have methodological limitations, and data on comparative safety versus standard therapies and on long-term durability of benefit are limited. Based on this evidence assessment, surgical deactivation of trigger sites for migraine does not meet Kaiser Permanente Medical Technology Assessment criteria and is considered not medically necessary.

Policy Metadata and Review Dates

Last review2024-09-03

Effective date

Next review

Policy statusCURRENT

Policy subjectSurgical deactivation of migraine trigger sites

Scope summaryClinical review criteria for surgical treatment (deactivation of trigger sites) of migraine headaches for Kaiser Foundation Health Plan of Washington members and providers; describes medical necessity conclusions, documentation to submit, and lists CPT and ICD-10 codes considered not medically necessary.