CurrentUnitedHealthcarePolicy CS086OH.E

Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Ohio Only)

UnitedHealthcare medical policy for Ohio members addressing clinical coverage positions on greater occipital nerve blocks (GONB), occipital nerve ablation and related procedures for occipital neuralgia, cervicogenic headache, migraine, cluster headache and pain due to malignancy of head/neck; includes definitions, evidence summary, and applicable procedure/diagnosis codes (part 1 of 5).

Policy Summary

PayerUnitedHealthcare

PolicyOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Ohio Only)

Policy CodePolicy CS086OH.E

Change TypeAdded documentation requirement; archived prior version

Effective DateDecember 1, 2025

Next Review Date

Key ActionPatient medical records must fully support medical necessity for requested services including relevant history, physical examination, and results of diagnostic tests or procedures; documentation must be legible and available upon request.

POLICY UPDATE CHANGES

Added language requiring that the patient's medical record must contain documentation that fully supports the medical necessity for requested services, including relevant history, physical exam, and results of diagnostic tests or procedures.

Archived previous policy version CS086OH.D

1State-specific (Ohio)

2Proven vs Unproven

25+Cited studies

9.3dMean MMD reduction (10 kHz SCS)

Coverage Summary

Concise overview: This UnitedHealthcare (Ohio-only) policy (effective December 1, 2025) addresses coverage positions on greater occipital nerve blocks (GONB), occipital nerve ablation and related interventional and surgical procedures for occipital neuralgia, cervicogenic headache, migraine, cluster headache and pain due to malignancy of the head/neck. Coverage stance: GONB and occipital nerve ablation are proven and medically necessary for pain due to malignancy involving the head and neck, whereas GONB (for headache indications), neurostimulation, neurectomy, rhizotomy, surgical decompression, and radiofrequency ablation are generally considered unproven and not medically necessary for occipital neuralgia and headache indications because of insufficient evidence. This policy applies only to Ohio and coverage decisions for services listed as unproven or limited will be evaluated under Ohio Administrative Code 5160-101.

Key Policy Attributes

State-specificOhio-only policy

Policy numberCS086OH.E

Effective dateDecember 1, 2025

Coverage stancemixed

Proven indication summaryInjection of local anesthetics and/or steroids (GONB) proven for pain due to malignancy involving head and neck

Unproven summaryMultiple procedures (GONB for headache indications, neurostimulation, neurectomy, rhizotomy, decompression, RFA) listed as unproven/not medically necessary for occipital neuralgia and headache indications

Evidence volumemultiple RCTs and systematic reviews cited

Members 18 Years of Age and Older

Policy statements for adults

ALL of the following

Injection of local anesthetics and/or steroids used as greater occipital nerve blocks are proven and medically necessary for treating pain due to malignancy involving the head and neck.
The following are unproven and not medically necessary for diagnosing and/or treating occipital neuralgia or headaches, including migraine and Cervicogenic Headaches:
- Injection of local anesthetics and/or steroids, used as greater occipital nerve blocks
- Neurostimulation or electrical stimulation

Members Under 18 Years of Age

Policy statements for pediatric members

ALL of the following

Proven and medically necessary for treating pain due to malignancy involving the head and neck:
- Injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs)
- Occipital nerve ablation (destruction by neurolytic agent)
The following are unproven and not medically necessary for diagnosing and/or treating occipital neuralgia or headaches, including migraine and Cervicogenic Headaches:
- Injection of local anesthetics and/or steroids, used as greater occipital nerve blocks

Evidence-based coverage implications

Evidence-based coverage implications (interpretive)

Findings summarized as assessments of sufficiency of evidence and comparative effectiveness:

ALL of the following

Greater Occipital Nerve Blocks (GONB) - multiple RCTs and systematic reviews report short-term reductions in pain intensity, headache days, and medication consumption; benefits often short-term; evidence limited by small sample sizes and short follow-up.
GONB with lidocaine or bupivacaine showed superiority to placebo in several RCTs for episodic and chronic migraine with reductions in headache days and VAS scores.
GONB for cluster headache (retrospective study) showed halted cluster bouts in 54.9% and high rates of VAS=0 at multiple post-treatment time points; limited by retrospective design and small size.
Surgical treatments (neurectomy, nerve decompression, various migraine surgeries) - evidence insufficient or low quality; some systematic reviews/meta-analyses report large reductions in frequency/severity but limitations include retrospective studies, heterogeneous methods, risk of bias and lack of RCTs.

Definitions

Definitions / common acronyms:

- Cervicogenic Headache → Referred pain in the head from a cervical source; disorder of the cervical spine and its components. (Cervicogenic Headache)

- Occipital Neuralgia (ON) → Pain syndrome attributed to occipital nerve irritation or injury. (Occipital Neuralgia)

- GON → Greater Occipital Nerve. (GON)

- GONB → Greater Occipital Nerve Block. (GONB)

- SON / SUPRAORBITAL NERVE (SON) → Supraorbital nerve. (SON)

- RFA → Radiofrequency Ablation (radiofrequency neurotomy). (RFA / RFN)

- PRF / PRFN / PRFT → Pulsed Radiofrequency / pulsed radiofrequency neuromodulation / pulsed radiofrequency treatment. (PRF / PRFN / PRFT)

- ONS → Occipital Nerve Stimulation (peripheral neurostimulation of occipital nerves). (ONS)

- REN → Remote Electrical Neuromodulation. (REN)

- MMD → Monthly Migraine Days. (MMD)

- MHD → Monthly Headache Days. (MHD)

- Neurectomy → Partial or total excision/resection of a nerve.

CPT / HCPCS / ICD-10 Codes Referenced

CPT / HCPCS / ICD-10 codes referencedmixed

63185	Laminectomy with rhizotomy; 1 or 2 segments.
63190	Laminectomy with rhizotomy; more than 2 segments.
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve.
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 neurostimulator electrode array and pulse generator.
64570	Removal of cranial 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.
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, initial electrode array.

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Provider Actions & Administrative Requirements

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation should be legible, maintained in the patient's medical record, and made available upon request. At minimum, include relevant medical history, physical examination findings, diagnostic test results, prior conservative therapy, and prior responses to diagnostic/therapeutic nerve blocks.

Document relevant medical history and physical exam findings supporting the diagnosis.
Record results of pertinent diagnostic tests or procedures (e.g., imaging, outcome questionnaires such as MIDAS/MSQ when applicable).
Document trials of conservative therapy (types, durations, dates) and clinical response or failure.
Document indication for the procedure, prior response to diagnostic or therapeutic occipital nerve block(s), and rationale for proceeding to neurotomy/ablation.
Include informed consent discussion noting limited long-term evidence for benefit and description of risks/complications.

Selected Evidence & Guideline Citations

Major guideline and evidence sources (selected):

- ANODYNE randomized trial (Chowdhury et al. 2024) — randomized placebo-controlled GONB trial in episodic cluster headache. (ANODYNE trial)

- Multiple systematic reviews and meta-analyses (2019–2024) summarizing mixed/low-quality evidence for GONB, RFA, surgical decompression, and neurostimulation. (systematic reviews)

- Hayes evidence assessments and research briefs (2019–2024) — evaluations of GONB, ONS, RFA and related interventions. (Hayes)

- ASPN/ASPN LEARN best-practice guidance for radiofrequency neurotomy recommending diagnostic blocks before RFN and favoring PRFN in some settings. (ASPN guidance)

- NICE interventional guidance on neurostimulation and transcutaneous SON stimulation emphasizing use with special arrangements for acute treatment and research for prevention. (NICE)

- American Headache Society (AHS) and Congress of Neurological Surgeons guidance on neuromodulation and ONS (including Level III or conditional recommendations). (AHS; Congress of Neurological Surgeons)

Evidence volume: the policy references a large body of literature (generally > 25 citations) including RCTs, systematic reviews, and device trials; overall evidence quality is heterogeneous with many short-term positive findings but limited long-term high-quality data.

Revision History

2025-12-01addedLatest

Added language requiring that the patient's medical record must contain documentation that fully supports medical necessity for requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the patient's medical record, and made available upon request.

2025-12-01archived

Archived previous policy version CS086OH.D as part of the revision history.

Policy Summary

PayerUnitedHealthcare

PolicyOccipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for Ohio Only)

Policy CodePolicy CS086OH.E

Change TypeAdded documentation requirement; archived prior version

Effective DateDecember 1, 2025

Next Review Date

On This Page

Occipital Neurectomy

Partial posterior intradural C1-C3 Rhizotomy

Radiofrequency ablation (thermal or pulsed) or denervation

Rhizotomy of C1-C3 spinal dorsal roots

Surgical decompression of second cervical nerve root and ganglion

Surgical decompression of the greater occipital nerve

Neurostimulation or electrical stimulation

Occipital Neurectomy

Partial posterior intradural C1-C3 Rhizotomy

Radiofrequency ablation (thermal or pulsed) or denervation

Rhizotomy of C1-C3 spinal dorsal roots

Surgical decompression of second cervical nerve root and ganglion

Surgical decompression of the greater occipital nerve

Neuroplasty / auriculotemporal nerve (ATN) decompression / supratrochlear/SON decompression - insufficient high-quality evidence; mostly nonrandomized studies, few comparative trials; conclusions on safety/effectiveness cannot be made.

Radiofrequency Ablation (RFA/PRF) - mixed evidence: RCTs and systematic reviews suggest favorable short-term outcomes for various headache types; some studies show PRF may be superior to repeated GONB for chronic migraine; evidence limited by heterogeneity, retrospective designs, small samples, and variable techniques; long-term (> 1 year) outcomes under-studied.

Overall: Interventional options may be reasonable for refractory cases but high-quality RCTs are generally lacking; long-term efficacy and ideal patient selection remain uncertain.

Background: Occipital neuralgia and cervicogenic headache are head pain syndromes arising from cervical spine or occipital nerve dysfunction (entrapment, compression, or C2–C3 root involvement). Treatments evaluated include greater occipital nerve blocks (GONB), peripheral neurostimulation/occipital nerve stimulation (ONS) and other peripherally implanted devices, surgical options (neurectomy, rhizotomy, decompression), and radiofrequency ablation (RFA) including pulsed radiofrequency (PRF).

Mechanisms and approaches: Percutaneous RFA uses an electrode to generate heat (thermal RFA) or pulsed electrical fields (PRF) to create a lesion or neuromodulatory effect in sensory nerves to inhibit pain signal transmission. Peripheral neurostimulation approaches include transcutaneous, percutaneous, and implanted lead-based stimulation with electrodes placed on or near target peripheral nerves (e.g., occipital, auriculotemporal, supraorbital, sphenopalatine ganglion) to modulate pain via electrical stimulation.

Study/Source	Key result
ANODYNE randomized trial (Chowdhury et al. 2024)
Weekly attack frequency change at week 4: −11.1 (active methylprednisolone+lignocaine) vs −7.7 (placebo); similar TEAEs; no serious adverse events.
GONB RCTs and meta-analyses (multiple sources: Cuadrado 2017, Gul 2017, Özer 2019, Shauly 2019, Tang 2017)
Multiple RCTs and pooled analyses show short-term reductions in pain intensity, headache days, and medication use versus placebo (pooled −3.6 headache days/month; pooled VAS reductions ≈2 points); follow-up mostly short-term.
Multiple systematic reviews/meta-analyses and Hayes assessments (2019–2024)
Systematic reviews report mixed/low-quality evidence that GONB provides short-term benefit; Hayes reviews rate evidence low and note limited support for chronic/long-term use.
RFA/PRF trials and systematic reviews (Ertilav 2024; Tanyel 2024; Jain 2024; Orhurhu 2021)
RCTs and reviews report favorable short-term outcomes; PRF often shows longer-lasting benefit vs repeated GONB in some trials; heterogeneity and limited long-term (>1 year) data noted.
Large retrospective/observational RFA series (Abd‑Elsayed 2024; Guo 2021)
Retrospective data report significant mean pain score reductions and prolonged mean duration of improvement (~254 days in one series) but are limited by study design and potential bias.
ONS / peripheral neurostimulation systematic reviews and trials (Kollenburg 2024; Hayes ONS reviews; Dodick et al. 2015)
ONS response rates variable across indications (approx. 35.7–100%); common AEs include lead migration/fracture (~13%) and local pain; evidence overall low-quality and long-term durability uncertain.
Remote Electrical Neuromodulation (REN) RCT (Tepper et al. 2023)
Multicenter RCT (n=248) showed REN reduced mean monthly migraine days vs placebo: therapeutic gain 2.7 days (p<0.001); no serious device‑related AEs.
10 kHz spinal cord stimulation prospective open‑label study (Al‑Kaisy et al. 2022)
Open-label (n=20) showed mean MMD reduction 9.3 days at 52 weeks; 50% converted to episodic pattern; no unanticipated device effects reported (small sample, nonrandomized).
Guideline summaries (AAPM, ASPN, NICE, AHS, VA/DoD)
Guidelines summarize limited/low-certainty evidence: AAPM gives weak recommendation for GONB in chronic migraine; ASPN recommends diagnostic blocks before RFN and favors PRFN; NICE and others advise use with special arrangements or in research for some neuromodulation approaches.

- Rhizotomy → Surgical section of a nerve root to relieve pain.

Prior Authorization

Consider prior authorization for surgical/interventional procedures

Prior authorization may be required for surgical or interventional procedures. Check the member's benefit plan and any applicable program-specific requirements (e.g., InterQual) before scheduling services.

Verify medical necessity via prior authorization when indicated by plan rules.
Use InterQual or other authorized clinical criteria where specified by contract or state rule.
Include submitted supporting documentation (history, exam, prior therapy, diagnostic block results) with the authorization request.

Documentation Required

Document evidence basis and limitations

When requesting coverage for neurotomy/radiofrequency ablation or other procedures with limited or uncertain evidence, explicitly document the clinical basis for treatment and prior management attempts. Note limitations of the evidence and the individualized rationale for care.

Document failure or intolerance of prior conservative therapies (medications, physical therapy, injections) including duration and outcomes.
Document prior response to diagnostic or therapeutic nerve block(s) if used to predict procedural benefit.
Include a clinician rationale that addresses why expected benefits outweigh risks given limited long-term evidence.
Record discussion with the patient about uncertainties in the evidence, alternative therapies, and potential risks/complications.

Documentation Required

Diagnostic blocks before neurotomy/RFN

Diagnostic blockade is typically recommended as a prerequisite prior to neurotomy or radiofrequency denervation to help identify pain generators and predict response to ablation, consistent with ASPN best-practice guidance.

Document the technique, agent(s), site(s), and clinical response to diagnostic blockade.
Record timing of diagnostic block relative to the planned neurotomy/RFN and the magnitude/duration of pain relief observed.

Note

Ohio-only application / Check applicable federal/state/contractual requirements

This policy applies only to Ohio. Providers must verify and comply with all applicable federal, state, and contractual requirements, including Ohio Administrative Code 5160-101 when evaluating services stated as unproven or subject to coverage/quantity limits.

Policy applies only to the state of Ohio — confirm member residency and applicable state rules.
Check federal/state/contractual requirements and any managed care carve-outs that may affect coverage.
Apply InterQual or other contract-specified clinical criteria where required by the contract or state rule.
Ensure prior authorization and documentation requirements specific to the member's plan are satisfied.