ModifiedUnitedHealthcarePolicy CS086NE.AB

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

Policy governing coverage and medical necessity for occipital nerve injections and ablation procedures (including occipital neuralgia and headache) for members in Nebraska.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS086NE.AB

Change TypeDefinitions addedstate-specific version created

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionDocument prior conservative therapy failure and, when applicable, a positive diagnostic or temporary stimulation trial (commonly ≥50%) to support authorization for invasive neurostimulation or ablative procedures.

SourceLink

POLICY UPDATE CHANGES

Created state-specific policy version for the state of Nebraska (no change to coverage guidelines).

Added definitions for the Migraine Disability Assessment Test (MIDAS) and Migraine-Specific Quality of Life Questionnaire (MSQ).

Updated reference link to reflect the current policy title for Ablative Treatment for Spinal Pain (for Nebraska Only).

Nebraska-onlystate applicability

20+ codescodes provided for reference

2022–2024recent evidence cited

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

no RCTs for some surgeries

85% successablation success (reported)

Coverage determinations and medical necessity

Prior Authorization

Prior Authorization and Documentation Requirements

Prior Authorization and Documentation — Provider Actions - Prior authorization is required for occipital nerve stimulation (ONS) and other implantable neurostimulation devices when the Plan/contract requires prior approval. Providers must verify Plan Authorization Requirements before scheduling procedures. UnitedHealthcare may use third-party criteria (for example, InterQual) to inform medical necessity and prior authorization decisions; evidence quality described in the policy (RCTs, systematic reviews, guideline recommendations) informs the PA determination and any utilization management review. - Providers should submit contemporaneous clinical documentation supporting all required elements at the time of prior authorization request, including prior treatments, diagnostic testing, response to diagnostic blocks, and objective outcome measures. Lack of required documentation may lead to denial or delay.

Prior authorization required where Plan/contract specifies (verify before scheduling).
Include diagnostic block results, trial response, documentation of conservative therapy, and outcome measures.
If PA is denied for lack of documentation, appeal with full records and rationale.

Step Therapy

Conservative Therapy, Step Therapy, and Diagnostic Blocks

Conservative Therapy and Stepwise Care — Provider Actions - A trial of standard medical therapy and conservative treatments is expected before invasive procedures such as RFA, surgical decompression, neurectomy, or implantation of neurostimulation devices. Conservative therapies include but are not limited to: optimized pharmacologic therapy (acute and preventive migraine medications), physical therapy, behavioral therapies, targeted injections (diagnostic or therapeutic GONB), and outpatient specialty management. - Document prior therapies: names/doses/dates of medications tried, duration and adherence, nonpharmacologic modalities attempted, and reason(s) for failure or intolerance. "Failure" generally means inadequate clinical response despite adequate dose and duration, or intolerance to therapy. - Diagnostic blocks: providers should document indication for diagnostic greater occipital nerve block (GONB), technique, agent(s) used, and objective response (pain scores, functional improvement). For procedures that require a diagnostic block (for example RFN/occipital neurotomy per specialty guidance), document a positive block and the magnitude and duration of response.

Expect trial of standard medical therapy first; conservative therapies before invasive procedures.
Diagnostic block prior to RFN and other targeted denervation: document positive response (magnitude & duration).
Document intervention failure definitions and why conservative care was inadequate.

Documentation Required

Special Arrangements and Research Use Requirements

Special Arrangements, Research Context, and Site Requirements — Provider Actions - For neurostimulation or newer transcutaneous electrical stimulation procedures where national guidance (eg, NICE, European Headache Federation) recommends "special arrangements" or use only in research/tertiary centers, verify whether the Plan requires that the procedure be performed within a recognized tertiary headache center or as part of an approved study. If so, include documentation of site credentials, multidisciplinary team involvement, and ethics/IRB approval where applicable. - When policies or guidelines state an intervention should be used in the context of research (NICE recommendations for certain transcutaneous SON procedures), providers must document enrollment in an approved study or local audit plan, patient consent reflecting uncertainties, and arrangements for clinical governance and outcome reporting.

Verify whether Plan/contract restricts device use to tertiary centers or studies; include site and team credentials.
If using under "special arrangements", provide written patient information, governance contacts, and audit/research documentation.
Document IRB/ethics approval or study ID when applicable.

Documentation Required

Outcome and Follow-up Documentation

Required Clinical Response and Outcome Documentation — Provider Actions - For prior authorization and ongoing management, include documented baseline and follow-up outcome measures commonly used in studies: pain intensity (eg, VAS/NRS), headache frequency (monthly migraine days or headache days), responder rates (≥30% and ≥50% reductions), MIDAS, HIT‑6, MSQ, and functional status. - For diagnostic blocks and therapeutic injections, report baseline pain, immediate and follow-up pain scores with time stamps (eg, 1 hour, 1 week), duration of relief, and any adverse events. - For neurostimulation devices, document results of any temporary trial (including threshold criteria — frequently a ≥50% reduction in pain or headache frequency during trial), device programming parameters, complications, and long-term follow-up outcomes (eg, 3, 6, and 12 months).

Include objective measures: VAS/NRS, MMD, MIDAS, HIT‑6, MSQ, responder rates.
For trials of ONS, document temporary trial response (eg, ≥50% reduction) and programming settings.
Follow-up documentation at standard intervals (eg, 3, 6, 12 months) and report adverse events.

Billing Rule

Documentation, Plan Rule Checks, and Governance

Operational and Plan Governance Checks — Provider Actions - Before submitting an authorization or performing a procedure, conduct a Documentation and Plan Rule Check: confirm member eligibility, verify Plan/contract benefit limits, confirm that the requested service is within policy scope (medical necessity vs investigational), and attach all supporting records (notes, imaging, prior authorization determinations, trial results). - The Plan/Contract Governance Requirement: when federal, state, or contractual requirements differ from this standard policy, those governing terms prevail. Providers should reference and attach any applicable state/federal authorization forms or mandates.

Verify member eligibility and plan-specific authorization requirements.
Attach clinical records, imaging, and prior trial documentation to the PA request.
If state/federal rules differ, follow and document the governing requirement.

Documentation Required

Supporting Documentation to Include with Authorization Requests

Support with Documentation — What to Submit - Provide clinical notes that document history, physical exam, diagnosis (use IHS diagnostic criteria when applicable), prior conservative therapies tried and duration, objective outcome measures, results of diagnostic blocks (including technique, agents, and response), imaging reports if performed to exclude alternative etiologies, and rationale for the requested invasive procedure. - For investigational or limited‑evidence interventions, include literature support and rationale for individual patient exception requests when seeking coverage.

Clinic notes, medication history, PT/behavioral therapy notes.
Diagnostic block procedure note with response and timing.
Imaging reports and specialist consultation notes when performed.

Prior therapy and step therapy requirements

Documentation of prior standard medical therapy may be relevant given comparative trial outcomes

Documentation of prior standard medical therapy: Document prior trials of standard medical therapy (e.g., ED or outpatient management such as IV metoclopramide, NSAIDs, triptans, antiemetics) before proceeding to GONB or other interventional procedures when comparative trials suggest medical therapy may be as or more effective.

Based on RCTs comparing GONB to IV metoclopramide and systematic reviews; documentation should record agents tried and response.

Failure of conservative and injectable therapies prior to considering surgical or ablative interventions

Failure of conservative and injectable therapies: Prior to considering surgical or ablative interventions (e.g., neurectomy, decompression, RFA), document failure of conservative care and prior injectable therapies such as GONBs or PRF when used diagnostically or therapeutically.

Multiple studies and RCTs imply RFA/PRF is considered after failed conservative and injectable therapies.

Documentation, prior authorization, and audit guidance

Billing Rule

Codes referenced — prior auth may apply

Procedure and device codes are provided for reference; inclusion does not guarantee coverage — providers should follow payer-specific prior authorization processes when submitting these CPT/HCPCS codes.

Examples include: 64405 (GONB), 64553/64555 (neurostimulator implantation), 64744 (transection of greater occipital nerve), 64633/64634 (destruction with imaging guidance).

Prior Authorization

Evidence quality will inform prior authorization

Prior authorization expectations may be informed by the low or heterogeneous quality of evidence (e.g., Hayes assessments characterizing GONB evidence as low-quality); reviewers may request short-term benefit demonstration and prior conservative therapy documentation.

Prior Authorization

Prior auth recommended for surgical/ablative procedures

Prior authorization is recommended for surgical or ablative procedures to review indication, prior conservative treatments, diagnostic block responses, and targeted nerve site before approving interventions.

Procedure, device, and diagnosis codes

Applicable CPT Codes (selection)CPT

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 (e.g., vagus nerve) neurostimulator electrode array and pulse generator.
64570	Removal of cranial nerve (e.g., 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.
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array.

1–10 of 13

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Applicable CPT/HCPCS Codes (additional)mixed

64634	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure).
64722	Decompression; unspecified nerve(s) (specify).
64744	Transection or avulsion of; greater occipital nerve.
64771	Transection or avulsion of other cranial nerve, extradural.
64999	Unlisted procedure, nervous system.
A4540	Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm.
L8679	Implantable neurostimulator, pulse generator, any type.
L8680	Implantable neurostimulator electrode, each.
L8685	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension.

Applicable ICD-10 CodesICD-10

C76.0	Malignant neoplasm of head, face and neck.
G89.3	Neoplasm related pain (acute) (chronic).

RFA device product codesmixed

GXD	FDA product code for radiofrequency lesion generators
GXI	FDA product code for radiofrequency lesion probes

Electrical stimulation device product codesmixed

GZF	FDA product code listed for electrical stimulation devices
GZB	FDA product code listed for electrical stimulation devices
PCC	FDA product code listed for electrical stimulation devices

Specific device clearancemixed

K203181

FDA 510(k) ID for Nerivio Migra (De Novo origin K203181 referenced)

MIDAS score

MIDAS score threshold>= 6 triggers need for provider discussion (MIDAS categories: 0-5 little/no disability; 6-10 mild; 11-20 moderate; 21+ severe)

MIDAS purposeQuestionnaire summing days from items 1-5 to assess migraine-related disability

MIDAS interpretation guidanceScore bands: 0-5 (little/no), 6-10 (mild), 11-20 (moderate), 21+ (severe) — use to inform treatment discussions

Billing Rule

Codes referenced — prior auth may apply (cross‑reference)

Procedure and device code list cross‑reference for prior authorization — see policy code tables; inclusion is informational and authorization requirements remain subject to plan rules.

Imaging and guidance used for procedures

Documentation Required

Use fluoroscopy or CT guidance for neurolytic/RFA procedures

Neurolytic destruction and radiofrequency ablation procedures are described as performed with imaging guidance per CPT descriptions; use fluoroscopic or CT guidance when indicated for neurolytic destruction.

Documentation Required

US guidance may be used for GONB (not universally required)

Ultrasound guidance for greater occipital nerve block was used in trials and is described in some protocols, though imaging guidance is not universally required for GONB.

Documentation Required

Image guidance (US/CT/fluoroscopy) often used for PRF/RFA/SPG

PRF, RFA, and SPG procedures use image guidance depending on the target; studies and protocols report use of ultrasound, CT, or fluoroscopy for needle/lead placement.

Dosing and repeat procedure guidance

GONB — up to four-weekly bilateral injections (12-week trial)

Frequency used in cited RCTFour-weekly bilateral GONB injections for 12 weeks (study by Chowdhury et al., 2023)

Injection contents in trial2 mL of 2% lidocaine per side (active) vs 2 mL 0.9% saline (placebo)

Primary endpoint timingChange from baseline across weeks 9–12 in average number of headaches and migraine days

GONB — repeated injections frequency guidance

Weekly repeated injections reportedSome studies performed GONB weekly for up to three weeks (e.g., Özer et al. 2019 and others)

Longer/maintenance schedulesRetrospective series described weekly x3 then monthly as needed for up to six months based on clinical response (Hasırcı Bayır et al. 2022)

Key terms and instruments

Cervicogenic Headache — definition

DefinitionCervicogenic Headache: Referred pain perceived in the head from a source in the neck; cause is a disorder of the cervical spine and its components (American Migraine Foundation)

Typical etiologiesMay arise from cervical spine bony, disc, and/or soft tissue elements

Use in policy contextDefinition used to distinguish headache referred from neck pathology when considering interventional treatments

Neurectomy — definition

Neurectomy definitionPartial or total excision or resection of a nerve (Taber's Medical Dictionary)

Clinical implicationSurgical removal of nerve segments aimed to relieve pain but evidence for long-term efficacy in ON is limited

Clinical context and evidence summary

Cervicogenic headache and occipital neuralgia are described as headache syndromes thought to originate from structures in the neck or from impingement/irritation of occipital nerves. Management options described range from medical therapies to local injections, percutaneous radiofrequency techniques, neurostimulation (transcutaneous, percutaneous, or implantable), and surgical procedures; the policy emphasizes that choice of intervention depends on diagnostic evaluation and the strength of evidence for each modality.

Procedures generally not covered

The policy’s Not Covered / Not Medically Necessary list reiterates procedures and technologies considered unproven for occipital neuralgia and headache indications. Items explicitly included are: neurostimulation/electrical stimulation for ON/headache, occipital neurectomy, rhizotomy (C1–C3), radiofrequency ablation/denervation (thermal and pulsed), surgical decompression of cervical nerve roots and greater occipital nerve, and other surgical neuroplasty techniques. Use of these procedures for ON/headache is not supported for routine coverage based on the current evidence base.

Policy changes and update notes

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS086NE.AB

Change TypeDefinitions addedstate-specific version created

Effective DateSeptember 1, 2025

Next Review DateN/A

SourceLink

On This Page

Document failure of conservative and medical therapies before advanced interventions

Document failure of conservative and medical therapies: Document that conservative and medical therapies have been tried and failed (including appropriate preventive and acute migraine medications) before advanced interventions such as neurostimulation or PRF are considered.

Multiple studies and reviews note neurostimulation/PRF is considered after failure of conservative therapy; selection often limited to refractory cases.

Documented failure of prior medical treatments and a positive temporary trial for invasive ONS

Documented failure and positive temporary trial for invasive ONS: For consideration of permanent invasive occipital nerve stimulation (ONS), document failure of prior medical treatments and a positive temporary trial (commonly defined as ≥50% reduction in pain lasting weeks) prior to permanent implantation.>=50% reduction

Hayes report: most permanent ONS implants were selected after a positive temporary trial; Congress of Neurological Surgeons supports ONS as option for medically refractory ON (Level III).

Medical therapy failure/refractory status indicated before invasive/device-based treatments

Medical therapy failure/refractory status before device-based treatments: Confirm and document that standard medical preventive and acute therapies have been optimized and failed prior to considering invasive or device-based treatments for migraine or occipital neuralgia.

NICE and other guidance emphasize medical therapy first; invasive treatments reserved for refractory patients.

Step Therapy

Trial of standard medical therapy expected first

Expect that standard medical therapies (e.g., ED/outpatient treatments such as IV metoclopramide or NSAIDs and other guideline-recommended medications) be tried before proceeding to nerve injections; documentation of prior standard medical therapy may be relevant.

Step Therapy

Conservative therapies required before procedures

Conservative, noninvasive therapies (oral analgesics, antiinflammatories, preventive medications) are identified as first-line; advanced interventions are considered after failure of conservative and injectable therapies.

Step Therapy

Require conservative therapy before advanced procedures

Document failure of conservative and injectable therapies before advanced surgical, ablative, or implantable procedures; many studies and reviews selected patients only after conservative measures failed.

Prior Authorization

Prior authorization required for permanent neurostimulation

Prior authorization is typically required for permanent neurostimulation implants; documentation should include failure of conservative treatments and evidence of clinically meaningful response to a temporary trial (commonly ≥30–50% pain reduction) and device-specific outcome measures.

Prior Authorization

Prior auth for ONS — positive temporary trial required

Prior authorization for occipital nerve stimulation (ONS) generally requires documentation of medical refractoriness and a positive temporary trial before permanent implantation; trials commonly use a ≥50% pain reduction threshold.

Note

Device regulatory information (FDA 510(k))

Devices used for RFA and electrical stimulation are regulated via the FDA 510(k) process with product codes listed (e.g., GXD, GXI for RFA; GZF, GZB, PCC for stimulation); FDA status is informational and does not guarantee coverage.

Prior Authorization

Verify plan authorization and contractual rules

Verify federal, state, and contractual benefit plan authorization requirements before using this policy; UnitedHealthcare may also use third‑party tools (e.g., InterQual) to assist in administering benefits.

Note

[No specific action specified in source for this item.]

Step Therapy

Diagnostic block required before RFN

Diagnostic occipital nerve block should precede occipital radiofrequency neurotomy (RFN); specialty guidance recommends diagnostic blockade before RFN and ruling out other etiologies with imaging as indicated.

Diagnostic block response (e.g., ≥50% relief) is commonly used to select patients for neurotomy.

Step Therapy

Conservative therapy required before invasive procedures

Conservative medical therapy must fail before considering invasive procedures; usual migraine treatments (acute and preventive) are first‑line and invasive options are reserved for refractory patients.

Note

[No specific action specified in source for this item.]

Documentation Required

Codes listed do not guarantee coverage — support with documentation

Listing of applicable codes in the policy is for reference only and does not guarantee coverage; documentation must support medical necessity per state/contract requirements.

Documentation Required

Include outcome and follow‑up measures in documentation

Studies commonly report outcomes such as headache frequency (days/month), pain intensity (VAS/NRS), analgesic consumption, MIDAS/HIT-6/MSQ, and follow-up time points; include these measures in prior authorization documentation when available.

Common reported outcomes: headache days/month, VAS or NRS pain scores, medication use, MIDAS/HIT-6/MSQ.

Documentation Required

Document prior diagnostic block and conservative therapy

Document a positive diagnostic block (commonly defined as ≥50% pain relief after targeted nerve block) and prior conservative management — multiple reviews associate prior positive block with better outcomes after RFA or surgery.

Documentation Required

Document prior therapy and trial response

Document prior conservative therapies tried and the patient's response to those trials; demonstration of failure of medical treatments is required before advanced interventions in many studies and for authorization.

Documentation Required

Document clinical response and follow‑up for temporary trials

For ONS, provide documentation of response to the temporary trial (baseline and follow-up attack frequency/intensity, and complications); trials commonly define a successful temporary trial as ≥50% reduction in pain.

Documentation Required

Documentation and audit requirements for special‑arrangement procedures

Maintain detailed procedural and outcome documentation to support audits and governance — include informed consent discussing uncertainties about safety/efficacy and systems to collect/report outcomes when required.

Billing Rule

Confirm plan rule check before authorization

Before submission, confirm plan rules and authorization checks; failure to follow contractual or plan rules may result in denial.

Note

Understand trial-defined intervention failure

Intervention failure in trials was defined variably (e.g., repeated GONBs, use of analgesics, need for epidural blood patch); such definitions may influence expectations about repeat procedures and coverage.

Denial Risk

Insufficient evidence may prompt denial

Procedures lacking sufficient evidence (e.g., occipital neurectomy or nerve decompression) may be denied due to inadequate long-term efficacy data from well-designed trials.

Denial Risk

Evidence insufficiency may trigger denial for neuromodulation

Low-quality or heterogeneous evidence for ONS, PRFN, and other neuromodulation approaches may lead to coverage denial or limitation when durable benefit or standardized protocols are not demonstrated.

Documentation Required

Temporary ONS trial documentation required

Document the temporary ONS trial and its results (commonly ≥50% reduction in pain lasting weeks); lack of documentation of a positive trial prior to permanent implant may lead to denial.

Denial Risk

Special arrangements (NICE) may be required

NICE recommends certain procedures (e.g., transcutaneous SON stimulation, some device implantations) only be used with special arrangements for governance, consent, audit, or research; lack of such arrangements may affect coverage.

Billing Rule

Follow plan/contract governance requirements

Coverage decisions must follow federal, state, or contractual plan governance; verify and follow plan/contract rules as they take precedence over this policy.

Documentation Required

CT or US guidance reported for SPG PRFT in studies

Protocols for pulsed radiofrequency treatment (PRFT) of the sphenopalatine ganglion and peripheral nerves in studies used CT or ultrasound guidance; document imaging used.

Documentation Required

MRI/CT recommended as clinically indicated before occipital RFN

Before occipital RFN, specialty guidance recommends ruling out other etiologies with MRI and/or CT as clinically indicated.

Documentation Required

Consider neuroimaging for first cluster headache bout

For a first bout of cluster headache, consider neuroimaging per guidance (discuss need with a specialist); document imaging decisions.

Caution on indefinite frequencyEvidence does not support indefinite, chronically frequent injections; trials and reviews recommend limited, protocolized schedules

C2 DRG pulsed RFA and other RFA procedures — frequency/series notes

C2 DRG pulsed RFA outcomesIn one series, 40% of patients had >=50% pain relief at 6 months after C2 DRG pulsed RFA (Lee et al. 2020)

Selection based on diagnostic blockC2 DRG pulsed RFA often performed for patients whose headache recurred after initial relief from C2 DRG block; positive block predicted success

Evidence qualitySystematic reviews report limited and low-quality evidence; larger RCTs needed to define optimal series/frequency

Pulsed radiofrequency treatments — frequency/series notes

PRF treatment durability and schedulesPercutaneous pulsed radiofrequency (PRFT/PRFN) studies report initial effectiveness with variable durability (e.g., supraorbital PRF: 77% effectiveness at 1–3 months; declines thereafter)

Use in cluster headache/SPGPRFT of the sphenopalatine ganglion reported rapid relief in refractory cluster headache series, but sample sizes were small and follow-up limited

Need for standardized protocolsStudies use varied single or repeated PRF sessions; evidence insufficient to define standard repeat intervals—further trials required

Occipital radiofrequency neurotomy (RFN) — repeat sessions and benefit duration

Repeat RFN sessions evidenceSpecialty guidance notes limited evidence to support repeat occipital RFN sessions; several studies documented benefit up to six months post-procedure (ASPN LEARN/consensus)

Diagnostic blockade prior to RFNDiagnostic occipital nerve blocks should precede RFN per best-practice guidance

Imaging and follow-upGuidance recommends ruling out other etiologies with MRI/CT before RFN and states longer follow-up data are needed to justify repeat sessions

Policy stanceOccipital neurectomy listed among procedures with insufficient evidence and considered not medically necessary for ON/headache in absence of supportive data

Rhizotomy — definition

Rhizotomy definitionSurgical section of a nerve root to relieve pain (Taber's Medical Dictionary)

Common targetsIncludes C1–C3 dorsal root procedures described in surgical approaches for occipital neuralgia/cervicogenic headache

Evidence notePolicy notes limited RCT evidence supporting rhizotomy for ON/headache and often classifies as unproven/not medically necessary

Intervention failure (study-defined)

Intervention failure (study-defined) examplesIn some post-dural puncture headache (PDPH) GONB trials, failure included need for repeated GONB, continued use of analgesics, or requirement for an epidural blood patch

Trial-specific endpointsStudies variably used recurrent procedures or additional interventions as failure outcomes — definitions differ across trials

Implication for coverageThese research-defined failure criteria inform expectations about repeat procedures in clinical practice and authorization reviews

Pulsed radiofrequency (PRF)

Pulsed radiofrequency (PRF) describedA non-destructive radiofrequency modality reported to have better safety and sometimes longer-term benefit compared to occipital nerve block alone in trials of chronic migraine and cervicogenic headache

ApplicationsApplied percutaneously to peripheral nerves or ganglia (e.g., occipital, supraorbital); used when conservative treatments fail

Evidence caveatStudies suggest benefit but overall evidence limited; RCTs are small and heterogeneous

Occipital nerve decompression/neurectomy — definition

Occipital nerve decompression/neurectomy describedSurgical procedures to relieve compression of occipital nerves (GON, LON) or to remove nerve segments; evidence is limited and primarily from observational studies

Reported outcomesSystematic reviews report high reported success rates in some series but note retrospective designs and lack of RCTs to confirm long-term efficacy

Policy implicationDue to limited high-quality evidence, these procedures are often considered investigational or not medically necessary for ON/headache

Pulsed Radiofrequency (PRFT/PRFN) — definition

PRFT/PRFN definitionPulsed Radiofrequency Therapy/Neurostimulation (PRFT/PRFN) is a non-ablative radiofrequency neuromodulation technique applied percutaneously to peripheral ganglia or nerves intended to reduce pain without destructive thermal lesioning

Reported usesUsed for supraorbital neuralgia, SPG, and other peripheral targets with variable durations of effect reported

Safety profileGenerally reported as safe with occasional transient adverse effects, but long-term comparative data are limited

Occipital Nerve Stimulation (ONS) — definition

ONS definitionOccipital Nerve Stimulation (ONS): Peripheral neurostimulation targeting occipital nerves using implantable leads to modulate pain transmission for chronic headache and occipital neuralgia

Trial selection practicePermanent ONS implants are typically preceded by a positive temporary trial (commonly ≥50% pain reduction), per studies and Hayes report

Outcome measuresStudies report responder rates, MIDAS, HIT-6, MSQ and reductions in monthly migraine days as common endpoints

Temporary ONS trial

Temporary ONS trial conceptTemporary trial of ONS used to select candidates for permanent implantation; commonly defined as >=50% reduction in pain lasting weeks in many studies

Documentation relevanceA positive temporary trial is commonly required in the literature and by prior authorization practice to justify permanent ONS

Responder thresholdsStudies variably use >=30% or >=50% responder definitions; >=50% is commonly reported in ONS selection

GONB — definition and evidence note

GONB definitionGreater occipital nerve block (GONB): Injection of local anesthetic +/- steroid at the greater occipital nerve used diagnostically or therapeutically for occipital neuralgia or headache

Evidence noteRCTs and systematic reviews show mixed/limited support for prevention of chronic migraine; some trials show short-term benefit depending on protocol

Policy classificationPolicy classifies GONB as unproven/not medically necessary for ON/headache generally, while noting proven use for malignancy-related head/neck pain in a separate statement

Transcutaneous electrical stimulation (eTNS/SON)

eTNS/SON definitionTranscutaneous electrical stimulation (eTNS/SON): External stimulation of the supraorbital nerve via a headband-like device applied to the forehead to reduce frequency/severity of migraine

Usage patternsApplied daily for prevention (~20 minutes) or for acute attacks (1–2 hours) depending on indication per NICE guidance

Evidence contextNICE rapid review included RCTs and case series; recommends special arrangements for use in some contexts due to limited evidence

RFA and device regulation

RFA/device regulation summaryRFA is a procedure; devices used to perform RFA are regulated via FDA 510(k) product codes (GXD for lesion generators, GXI for lesion probes)

Implication for coverageDevice 510(k) clearance is informational and does not by itself determine coverage or clinical effectiveness

Reference linkFDA 510(k) database referenced for additional device details (accessed March 17, 2025)

MIDAS — definition

MIDAS definitionMigraine Disability Assessment Test (MIDAS): questionnaire summing days from items 1–5 to assess migraine-related disability

Use in policyAdded to Definitions section to support outcome measurement and documentation of disability in coverage considerations

Scoring guidanceMIDAS score >=6 indicates need for provider discussion (per National Headache Foundation) — score bands provided in policy

MSQ — definition

MSQ definitionMigraine-Specific Quality-of-Life Questionnaire (MSQ): 14-item self-report measuring role, emotional and social functioning impact of migraine

Scoring formatItems rated on 6-point Likert scale (1 very poor to 6 very good); used in trials to capture quality-of-life changes

Policy inclusionAdded to Definitions section to support device/outcome reporting (e.g., ONS and SCS studies report MSQ improvements)