CurrentKaiser PermanentePolicy N/A

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

Defines Kaiser Permanente Washington coverage stance and clinical review criteria for surgical treatment (deactivation of trigger sites) of migraine headaches for plan members and providers.

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 or coverage changes

Effective DateFeb 1, 2022

Next Review DateN/A

Key ActionVerify pre-authorization requirements and submit recent clinical notes and the last 2 years of neurology notes when requesting this service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2randomized controlled trials identified

Multiplecodes listed as not medically necessary

A-0578MCG guideline referenced

WAapplicable state

Coverage Determination and Criteria

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General coverage determination

Covered only when specific evidence-based criteria are met; otherwise considered not medically necessary per MCG and Kaiser review.

Evidence and guideline basis: Kaiser used MCG Migraine Headache, Surgical Treatment (A-0578) for non-Medicare determinations and reviewed available randomized controlled trials; overall conclusion: surgical deactivation does not meet Kaiser Permanente Medical Technology Assessment criteria due to limited evidence, methodological limitations in the RCTs, and uncertain long-term efficacy.

Evidence includes two RCTs and limited long-term data; MCG states these procedures are not covered for non-Medicare members.

Kaiser Permanente Washington follows the MCG guideline (Migraine Headache, Surgical Treatment A-0578) and a Kaiser review of the available evidence in determining coverage for surgical deactivation of migraine trigger sites. The evidence review identified two randomized controlled trials with methodological limitations and limited long-term outcome data; overall, the procedure does not meet Kaiser Permanente Medical Technology Assessment criteria. As a result, surgical deactivation is generally not covered except in the limited circumstances where specific, evidence-based criteria documented by MCG and reviewed by Kaiser are met.

Codes and Billing

Considered Not Medically Necessary CPT codesCPTNot Covered

15824
15826	Rhytidectomy; glabellar frown lines
21299	Unlisted craniofacial and maxillofacial procedure
30520
30801	Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method: superficial
30802	Ablation, soft tissue of inferior turbinates; intramural (submucosal)
31200
31201	Ethmoidectomy, intranasal, total
31205	Ethmoidectomy, extranasal, total
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)

1–10 of 15

1/2

Considered Not Medically Necessary ICD-10-CM codes (selected examples)ICD-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
G43.111	Migraine with aura, intractable, with status migrainosus
G43.701	Chronic migraine without aura, not intractable, with status migrainosus
G43.709	Chronic migraine without aura, not intractable, without status migrainosus
G43.911	Migraine unspecified, intractable, with status migrainosus
G43.919	Migraine unspecified, intractable, without status migrainosus

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for surgical procedures related to migraine trigger-site deactivation. To verify whether a specific CPT/HCPCS code requires prior authorization under the member's plan, use the Pre-authorization Code Check tool and confirm requirements for the member's plan type before scheduling.

Use the Pre-authorization Code Check to confirm authorization requirements by plan type.
Obtain authorization prior to performing any procedure listed in the Not Medically Necessary code lists to avoid denial risk.

Step Therapy

Conservative Therapy Required First

Patients must have attempted and failed an adequate course of conservative (non‑surgical) therapy before surgical consideration. Conservative therapy includes identification and avoidance of triggers, appropriate acute pharmacotherapy, and preventive pharmacologic management. Diagnostic confirmation of trigger-site responsiveness (for example, ≥50% improvement in pain intensity or frequency after Botox or a diagnostic nerve block) should be documented prior to proceeding to surgery.

Documented trial of standard medical management (trigger avoidance, acute and preventive medications).
Evidence of trigger-site identification and positive diagnostic response (≥50% improvement) with Botox or local nerve block.

Documentation Required

Required Documentation

Submit the following documentation to support medical necessity when requesting authorization: most recent clinical note from the requesting provider; neurology notes from the past 2 years; documentation of trials and responses to conservative therapies (medication history, trigger avoidance measures); records of diagnostic trigger-site testing (Botox or nerve block) and objective response; and relevant operative or specialty consultation notes.

Most recent clinical note from requesting provider.
Last 2 years of neurology notes.
Medication history and documentation of preventive and acute therapy trials.
Documentation of diagnostic trigger-site testing and response (Botox or local nerve block).
Consultation notes and any prior surgical evaluations.

Denial Risk

Not Medically Necessary Codes — Denial Risk

Procedures and associated diagnosis codes listed in the "Considered Not Medically Necessary" sections are subject to denial if billed. Verify coding and medical necessity carefully; if a listed code is submitted, expect review and possible denial.

All CPT/HCPCS and ICD-10 codes listed under "Considered Not Medically Necessary" (e.g., 15824, 15826, 21299, 30520, 30801, 30802, 31200, 31201, 31205, 31254, 31255, 64732, 64734, 64744, 67900 and related ICD-10 G43.* codes).
Codes in the Not Medically Necessary lists may not be all-inclusive; deleted or out‑of‑effect codes may also be denied.

Clinical Background

Migraine is a primary headache disorder characterized by recurrent attacks that can include unilateral head pain, nausea, photophobia, and visual disturbances. Surgical deactivation targets peripheral ‘‘trigger sites’’ thought to initiate migraine attacks; candidate sites are commonly identified using diagnostic local injections such as botulinum toxin (Botox) or local nerve blocks. Surgical approaches vary by trigger site and may include removal or modification of soft tissues, nerve transection, or sinus procedures. The evidence base consists mainly of observational studies and two RCTs from the same investigator group; because of methodological limitations and limited long-term data, surgical deactivation is considered an investigational/limited therapy and does not meet Kaiser’s criteria for routine coverage.

Key Definitions

inv-11: Trigger site identification — definition and criteria

DefinitionUse of Botox injections or local peripheral nerve blocks to identify peripheral nerve or muscle sites triggering migraine; identification is based on complete elimination or ≥50% improvement in headache intensity and/or frequency following injection.

PurposeTo locate peripheral trigger sites where surgical deactivation may reduce migraine frequency or intensity.

Common methodsMost investigators use onabotulinumtoxinA (Botox) for diagnostic identification; local nerve blocks are an alternative.

Candidacy thresholdPatients achieving complete elimination or at least 50% improvement after diagnostic Botox or nerve block are considered candidates for surgery.

Clinical contextTypically used for patients not receiving adequate benefit from standard medical treatments (trigger avoidance, acute and preventive pharmacotherapy).

inv-12: Surgical deactivation — approaches and notes

DefinitionSurgical deactivation refers to operative procedures targeting identified peripheral trigger sites to eliminate migraine triggers by modifying or removing implicated tissues or nerves.

Typical approachesMay include removal of certain facial muscles, transection/severing of facial or occipital nerves, and surgical modification of the paranasal sinuses.

Evidence summaryTwo randomized controlled trials with methodological limitations and limited long-term data suggest possible benefit but overall safety and long-term efficacy are uncertain.

Role in care pathwayConsidered for patients who fail standard medical therapy after trigger identification shows ≥50% improvement with diagnostic injection/block; overall does not meet Kaiser Medical Technology Assessment criteria due to limited evidence.

Implication for coverageBecause of limited and uncertain evidence, surgical deactivation is not supported as meeting Kaiser Permanente Medical Technology Assessment criteria; coverage is restricted per policy determinations.