RetiredUnitedHealthcarePolicy CS086LA.W

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

State-specific UnitedHealthcare medical policy for Louisiana covering indications, proven and unproven treatments for occipital neuralgia and related headaches; affects providers treating Louisiana Medicaid members (policy header indicates Louisiana application).

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS086LA.W

Change TypeRetirement and clarifications (state-specific code note, definitions added, evidence update)

Effective DateNovember 1, 2025 - March 31, 2026

Next Review DateN/A

Key ActionVerify benefit coverage and prior authorization requirements with the member's Louisiana benefit plan before submitting claims or requesting authorization, noting A4540 may not be covered by Louisiana Medicaid.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

Noted HCPCS A4540 is not on the State of Louisiana Medicaid Fee Schedule and may not be covered by State Medicaid.

Definitions added for MIDAS and MSQ.

Clinical Evidence and References sections updated.

1state-specific (LA)

1 Apr 2026policy retired date

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.

~30+references cited

Coverage Criteria and Evidence Summary

Medically necessary (malignancy-related pain)

Covered when ALL of the following are met

Proven and medically necessary for malignancy-related head/neck pain: Injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs) and occipital nerve ablation (destruction by neurolytic agent) are proven and medically necessary for treating pain due to malignancy involving the head and neck.

From Coverage Rationale.

Unproven / Not medically necessary

Not medically necessary / Unproven for diagnosing and/or treating occipital neuralgia or headaches (including migraine and cervicogenic headache):

Unproven/Not medically necessary interventions: Injection of local anesthetics and/or steroids used as greater occipital nerve blocks; 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.

Listed explicitly in Coverage Rationale.

Short-term efficacy

Summary of coverage-relevant evidence considerations

Evidence-supported short-term benefit: Randomized trials and meta-analyses show GONB can reduce pain intensity and headache days in the short term (hours to weeks)—for example, therapeutic effects for PDPH up to 24 hours and reductions in headache days in migraine trials; short-term randomized trials report improvements but study sizes are small and follow-up short.short-term follow-up

Quality of evidence often rated low; many trials small and heterogeneous

Insufficient long-term evidence

Limitations and implications for longer-term or surgical interventions

Insufficient evidence for chronic preventive use and some surgical procedures: Systematic reviews and HTA reports find low-quality evidence for chronic or preventive benefit of repeated GONB and insufficient high-quality data for neuroplasty and many surgical approaches; longer-term benefit is not established and authors call for larger RCTs with longer follow-up.long-term follow-up absent or inadequate

Authors call for larger RCTs and longer follow-up

Surgery outcomes (select studies)

Evidence on migraine surgery outcomes

Surgical outcomes may show substantial benefit in selected studies: Meta-analyses report reductions in headache frequency, severity, and migraine headache index after migraine trigger-site surgery, with pooled estimates (e.g., ~38% elimination of migraine at 6–12 months) and large odds ratios versus sham in limited RCT data, but study heterogeneity and risk of bias limit certainty.6-12 months outcome

Additional rigorous randomized trials recommended

Evidence-based candidate indicators (literature-derived)

Evidence-supported candidate characteristics and outcomes noted in literature

Suggested candidate-selection indicators: Patient has refractory occipital neuralgia, cervicogenic headache, or chronic migraine after failure of conservative therapy; patient had a diagnostic nerve block with a definite positive response (commonly defined or associated with ≥50% pain relief); care provided by or in consultation with a neurology or pain specialist.diagnostic block ≥50%

Based on association of prior block/trial response with better outcomes in multiple reviews and cohort studies

Insufficient evidence procedures

Procedures with insufficient high-quality evidence

Procedures lacking sufficient evidence: Occipital neurectomy and decompression (including supraorbital, supratrochlear, zygomaticotemporal and greater occipital nerves), and some forms of nonpulsed (thermal) percutaneous radiofrequency ablation: long-term efficacy not established in well-designed clinical trials.

Multiple systematic reviews noted inadequate RCT evidence or heterogeneous, low-quality studies

Coverage-relevant criteria and considerations

Coverage-relevant findings and common selection criteria reported in the studies and reviews:

Implantable neurostimulation patient selection: Many studies selected patients for permanent implantation after a positive temporary trial, commonly defined as ≥50% reduction in pain that lasted for a few weeks; documentation of trial response is commonly used for candidate selection.>=50% pain reduction

Retrospective and prospective series commonly used trial-based selection

Evidence strength for different modalities: Noninvasive neuromodulation (e.g., REN) has randomized trial evidence showing benefit for some migraine indications; implantable ONS/PNS/SCS evidence is generally low to very low quality with variable responder rates.

See REN randomized trial and Hayes assessments

Complication and device risk consideration: Implantable devices report complications including lead migration/fracture, infection, and reoperation (reported device removal rates up to ~27% in some series); these risks factor into assessment of medical necessity for implantation.

Summarized coverage-related clinical criteria and guideline positions

Evidence and guideline-derived positions summarized below reflect indications, effectiveness, and required preceding steps where noted.

Occipital Nerve Stimulation (ONS): Guideline and HTA summaries describe very low-quality evidence for ONS in some indications (e.g., chronic cluster headache) with some reported short-term efficacy but notable complication and reoperation risks; use generally limited to specialized centers or research contexts.

Hayes HTA and NICE statements reflect limited evidence and governance requirements

SPG stimulation: Randomized sham-controlled trial demonstrated acute pain relief benefit at 15 minutes versus sham in chronic cluster headache (Goadsby et al.), supporting consideration as an acute treatment option with attention to device-related adverse events.

RCT evidence for acute efficacy

Noninvasive neuromodulation (eTNS, REN, TENS, PENS, rTMS): Systematic reviews and RCTs show mixed but sometimes positive results: REN has RCT evidence for migraine prevention; several noninvasive modalities show preventive or acute benefit in small or low-quality trials—overall evidence quality often rated low and further well-conducted trials are needed.

Guideline-based coverage considerations

Guideline summaries and recommendations relevant to coverage decisions

VA/DoD on neuromodulation for migraine: 2023 VA/DoD: insufficient evidence to recommend for or against multiple forms of neuromodulation (noninvasive vagus nerve stimulation, supraorbital/external trigeminal nerve stimulation, remote electrical neurostimulation, external combined occipital and trigeminal systems, rTMS, tDCS); insufficient evidence to recommend for or against GONB for preventing chronic migraine; recommends OnabotulinumtoxinA for prevention of chronic migraine but not for episodic migraine.

Guideline statements summarizing evidentiary uncertainty.

NICE on transcutaneous SON stimulation: NICE (2022): evidence adequate for acute SON stimulation treatment but limited for subsequent attacks; acute use should be only with special arrangements for governance, consent, audit/research; evidence inadequate for prevention — should be used only in research. Clinicians must document outcomes and follow governance/audit requirements.

NICE requires audit, outcome collection, and specialist patient selection.

NICE and ONS/SPG statements: NICE: ONS shows some short-term efficacy but little long-term evidence and risk of complications; SPG stimulation has RCT evidence for acute pain relief; both procedures are recommended only with special arrangements and research/audit to collect outcomes.

The policy states that the following procedures are unproven and not medically necessary for diagnosing or treating occipital neuralgia or headaches (including migraine and cervicogenic headache): injection of local anesthetics and/or steroids used as greater occipital nerve blocks (except when treating head/neck malignancy), neurostimulation or electrical stimulation, occipital neurectomy, partial posterior intradural C1–C3 rhizotomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy of C1–C3 dorsal roots, surgical decompression of the second cervical nerve root and ganglion, and surgical decompression of the greater occipital nerve.

No single procedural exclusion beyond the list of unproven interventions is specified; however, systematic reviews and HTAs note the lack of evidence for chronic, long‑term use of greater occipital nerve blocks (GONB), which may functionally exclude repeated or maintenance GONB for chronic prevention in the absence of stronger supporting data.

The long‑term efficacy of occipital neurectomy or nerve decompression for headaches is not established: available studies and reviews concluded there is insufficient evidence from well‑designed clinical trials to support sustained benefit from these surgical approaches.

Occipital nerve stimulation (ONS) for chronic cluster headache is supported by a small and very low‑quality evidence base; the studies reviewed were heterogeneous, limited in size, and provide substantial uncertainty about generalizability and long‑term effectiveness.

The European Headache Federation advises that neurostimulation devices should be used only for medically intractable syndromes at tertiary headache centers, and then only as part of valid studies or where effectiveness has been demonstrated in controlled trials—i.e., use should be restricted to research or specialist settings until stronger evidence is available.

Botulinum toxin A is not specifically FDA‑approved for cervicogenic headache or occipital neuralgia; its use for these diagnoses is therefore off‑label.

This Louisiana‑specific policy version was retired effective 04/01/2026; Louisiana plan membership was disenrolled from this policy as of that date.

The policy addresses a range of modalities commonly considered for occipital neuralgia and related headaches, including greater occipital nerve blocks (GONB), neurostimulation/electrical stimulation (ONS, PNS, noninvasive devices), occipital neurectomy, rhizotomy, radiofrequency ablation (thermal and pulsed), and surgical decompression/neuroplasty.

Evidence reviews find that GONB can provide short‑term relief of headache symptoms compared with placebo, but the overall quality of evidence is rated as low and there is little to no evidence supporting chronic, long‑term preventive benefit; therefore use of GONB for sustained preventive therapy lacks sufficient evidence and may be considered not medically necessary for chronic prevention.

For nonpulsed (thermal) percutaneous radiofrequency ablation (RFA) to treat occipital neuralgia, an abstract‑level review found that there is currently insufficient peer‑reviewed literature (no RCTs or systematic reviews identified) to perform a full evidence assessment.

Multiple procedures lack well‑designed randomized controlled trials demonstrating superiority to sham or established treatments; reviews conclude that the available studies are limited, methodologically flawed, and generally provide only low‑to‑very‑low quality evidence.

ONS for chronic cluster headache is supported by very low‑quality evidence with small study sizes and methodological limitations, resulting in substantial uncertainty about effectiveness and generalizability.

Multiple guideline and evidence sources report insufficient or limited evidence for various neuromodulation methods (invasive and noninvasive), and recommend that many such therapies be used only within research settings or with special arrangements for governance, audit, and specialist selection.

Applicable Codes and Clinical Thresholds

Prior Authorization

Callout — Provider Action

Provider action: Verify coverage and prior authorization requirements for all applicable codes before billing; inclusion in the code list does not guarantee coverage.

Codes on the State of Louisiana Medicaid Fee Schedule may differ; codes marked with an asterisk (*) in the code list are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program.

Applicable CPT codesCPT

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
64596	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator; initial electrode array

1–10 of 18

1/2

Applicable HCPCS / Device CodesHCPCS

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
C76.0	Malignant neoplasm of head, face and neck (ICD-10)
G89.3	Neoplasm related pain (acute) (chronic) (ICD-10)

State-specific code notemixed

A4540

Not on State of Louisiana Medicaid Fee Schedule — may not be covered

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

PA recommended for surgical procedures; document conservative failure

Surgical interventions (eg, neurectomy, neuroplasty, other migraine-trigger site surgeries) have limited, heterogeneous, and low-quality evidence; prior authorization may require documentation of failed conservative therapies and a clear surgical rationale with expected benefit.

"The available evidence is insufficient to conclude that surgery is an effective treatment for ON or cervicogenic headaches."
"Prior authorization may require documentation of prior conservative therapies and detailed surgical rationale and expected benefit."

Note

Prior authorization requirements (not specified)

Not present in this excerpt.

Prior Authorization

PA for implantable neurostimulation often requires trial documentation

Implantable neurostimulation (ONS, PNS, SCS) is typically preceded by a temporary trial and many studies selected patients for permanent implantation after a positive trial (commonly ≥50% pain reduction); prior authorization may require evidence of a documented temporary trial response and failed conservative therapy.

Conservative Therapy and Trial Requirements

Consider prior/stable preventive medication use when interpreting trial applicability

Consider prior/stable preventive medication use when interpreting trial applicability.

Stable preventive regimen in cited trials: Clinical trials referenced often required participants be off preventive medications or on a stable preventive medication regimen for at least 3 months; consider prior/concurrent preventive medication status when assessing applicability of trial results to an individual patient.stable preventive regimen for at least 3 months

From trial inclusion criteria and trial descriptions; affects generalizability

Failure of standard medical therapies prior to authorization of repeated GONB or surgical procedures is implied by evidence limitations

Failure of standard medical therapies implied before repeated GONB or surgery: Evidence syntheses recommend conservative care and note limited benefit for chronic use of GONB; payer programs may require failure of standard medical therapies before authorization of repeated GONB or surgical procedures.

Treatment Frequency and Trial Durations

GONB (trial regimen)

GONB trial regimen (RCT)Four-weekly bilateral GONB injections for 12 weeks (active arm received 2 mL of 2% lidocaine per block)

Population in trialParticipants with chronic migraine in randomized, double-blind, placebo-controlled study (Chowdhury et al. 2023)

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

GONB — reported frequencies

Reported GONB frequencies in studiesSingle blocks or short series (eg, weekly x3) reported in retrospective and prospective studies

Common clinical practiceSeries of weekly blocks for three weeks then monthly maintenance based on clinical response (Hasırcı Bayır et al. 2022)

Imaging and Procedural Guidance

Billing Rule

Use and document fluoroscopy/CT for neurolytic/RF procedures per CPT

Fluoroscopy or CT imaging guidance is referenced in CPT descriptors for destruction by neurolytic agent and radiofrequency procedures; perform and document imaging guidance per CPT when applicable.

"64633...including imaging guidance (fluoroscopy or CT)."
"Destruction by neurolytic agent...with imaging guidance (fluoroscopy or CT)"

Billing Rule

Ultrasound commonly used for GONB — document guidance used

Ultrasound guidance is commonly used for GONB in trials and may be used for procedural placement; document imaging modality used.

"Elsayed et al. 2023...compared distal and proximal ultrasound (US)-guided bilateral GONBs."
"Some studies used ultrasound guidance for GONB..."

Not Covered / Exclusions

Not covered (per policy statements and the not‑medically‑necessary list) includes neurostimulation or electrical stimulation for occipital neuralgia/headache (unless covered for malignancy‑related pain per plan), occipital neurectomy, and related procedures; these interventions are identified as unproven or not medically necessary for ON/headache indications.

Duplicate entries in the not‑covered listing reiterate that neurostimulation/electrical stimulation and surgical neurectomy approaches are considered unproven and not medically necessary for ON/headache indications outside the malignancy‑related exception.

Additional reiteration of not‑covered items emphasizes that denervation, rhizotomy, and surgical decompression procedures are repeatedly identified in the policy as unproven or not medically necessary for occipital neuralgia/headache treatment.

Policy language consistently lists radiofrequency ablation (thermal or pulsed) and rhizotomy of C1–C3 dorsal roots among interventions deemed unproven and not medically necessary for ON/headache indications.

Surgical decompression of the greater occipital nerve and surgical decompression of the second cervical nerve root and ganglion are explicitly listed as unproven and not medically necessary for occipital neuralgia/headache in the policy.

Not‑medically‑necessary determinations reflect the limited quality and quantity of evidence for many implantable neurostimulation indications; absence of robust controlled data supports a noncoverage posture absent stronger supportive evidence.

Definitions and Terminology

Cervicogenic Headache — definition

DefinitionCervicogenic headache: referred pain perceived in the head from a source in the neck due to disorder of the cervical spine and its components (American Migraine Foundation, 2016)

Clinical contextMay arise from bony, disc, or soft tissue elements of the cervical spine

Use in policyDefined to clarify indications and differential diagnosis for occipital nerve interventions

MIDAS (Migraine Disability Assessment Test)

MIDAS — tool descriptionA self-report questionnaire measuring the impact of headaches on daily function; total of days from questions 1–5 are summed to produce score

Score bands0–5 little/no; 6–10 mild; 11–20 moderate; 21+ severe

Background and Scope

Cervicogenic headache and occipital neuralgia are described as head pain syndromes thought to arise from occipital nerve entrapment or disorders of the upper cervical spine; management spans conservative care, nerve blocks, radiofrequency procedures, neuromodulation, and surgical approaches, but evidence for many invasive procedures is limited or inconsistent.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS086LA.W

Change TypeRetirement and clarifications (state-specific code note, definitions added, evidence update)

Effective DateNovember 1, 2025 - March 31, 2026

Next Review DateN/A

SourceLink

On This Page

Adverse event rates vary by study

AHS supports offering neuromodulatory devices when medication response is inadequate or not tolerated

Occipital radiofrequency neurotomy (RFN): Best-practice summaries recommend diagnostic occipital nerve block prior to RFN and MRI/CT to exclude other etiologies; PRF techniques are often preferred in evidence summaries with documented pain relief up to six months in several studies.

Use diagnostic blocks to identify candidates; imaging recommended before RFN

Supports restricted use in research or specialist settings.

"In all but one study, individuals were selected for permanent ONS implantation based on a positive response to a temporary trial...typically, a ≥ 50% reduction in pain"
"Documentation of trial response and prior failed conservative therapy may be required for PA."

Documentation Required

Document diagnostic block and MRI/CT before occipital RFN

Before occipital radiofrequency neurotomy (RFN), diagnostic occipital nerve blockade should be performed and MRI and/or CT imaging used to exclude other etiologies; clinicians should document these pre-procedure evaluations.

"Diagnostic blockade of the occipital nerves should precede the use of RFN."
"Before RFN of the occipital nerves, other possible etiologies should be ruled out through either magnetic resonance imaging (MRI) and/or computerized tomography (CT) imaging."

Note

Device regulatory status noted (informational)

Device regulatory status for RFA and electrical stimulation devices is noted (FDA 510(k) listings and De Novo pathway for at least one device); this information is informational and does not by itself determine coverage.

"There are numerous devices listed in the FDA 510(k) database approved for use in performing RFA."
"Nerivio Migra was granted a class II designation through the De Novo review process..."

Prior Authorization

LA policy retirement and state fee-schedule implications (A4540)

This Louisiana-specific policy version was retired effective 04/01/2026; HCPCS code A4540 is flagged as not on the State of Louisiana Medicaid Fee Schedule and prior authorization and coverage for such codes are subject to state fee-schedule and contract terms.

"Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026."
"Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program."

Documentation Required

Consider prior/stable preventive medication status

When assessing trial applicability and outcomes, consider whether patients were on stable preventive medication regimens (trials often required stability for at least 3 months); document prior or concurrent preventive medications.

"Clinical trials referenced often included participants not on preventative medications or on stable doses for at least three months."
"One trial...consisted of a baseline period of four weeks...four-weekly bilateral GONB...for 12 weeks."

Step Therapy

Require failure of conservative therapy before advanced interventions

Evidence reviews and guideline summaries recommend trying conservative medical therapies before repeated GONB, surgical procedures, or implantable interventions; payer programs may require documentation of failure of standard medical therapies prior to authorization.

"Little to no evidence meeting inclusion criteria was found around benefit of chronic use of this therapy."
"Conservative therapies and standard care should be tried before repeated blocks or surgical interventions."

Step Therapy

Conservative-first/step approach reflected in studies

Many published studies and trials compared RFA/PRF and other ablation procedures to less invasive interventions such as occipital nerve blocks (GONB), reflecting a conservative-first, stepwise approach in the literature.

"Ertilav et al. (2024) ... compared repeated GONB and pulsed radiofrequency therapy."
"Tanyel et al. (2024) conducted a double blind, RCT...comparing GONB and GONB+PRF."

Step Therapy

Patients typically fail conservative therapy before invasive procedures

Studies frequently enrolled patients who had failed conservative therapies before receiving invasive treatments; neurostimulation trials commonly evaluated devices after noninvasive or medical options were inadequate.

"Studies and systematic reviews commonly included patients who failed conservative therapies prior to PRFT, ONS, PNS, or SCS interventions."
"REN trial enrolled participants and demonstrated benefit as a device studied for prevention after baseline observation."

Step Therapy

Try pharmacologic/noninvasive therapies before neuromodulation

Guidelines recommend trying pharmacologic and other noninvasive treatments first; neuromodulatory devices are generally suggested for patients with inadequate response or intolerance to medications.

"The AHS indicates that all patients with a confirmed diagnosis of migraine may be offered treatment with a neuromodulatory device...Patients with an inadequate response to a migraine-specific medication...should be considered for a trial of a neuromodulatory device."
"The usual treatment options for migraines are medical therapies...Invasive treatments are reserved for people with distressing symptoms that are refractory to medical therapy."

Documentation Required

Document medical therapy attempts before invasive procedures (NICE)

NICE states usual migraine treatments are medical therapies and invasive treatments are reserved for refractory cases, implying conservative therapy should be attempted before invasive neuromodulation or procedures.

"Invasive treatments are reserved for people with distressing symptoms that are refractory to medical therapy."

Billing Rule

Coding list provided for reference; verify coverage

Applicable CPT/HCPCS/ICD codes are provided for reference; inclusion does not guarantee coverage or payment and should be used only to support coding and benefit verification.

"The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only...Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service."

Documentation Required

Document baseline and follow-up headache outcomes

Clinical outcome documentation typically expected includes baseline and follow-up headache frequency, pain intensity (eg, VAS/NRS), acute medication/analgesic use, and any adverse events; provide objective outcome measures when requesting coverage.

"Studies frequently document baseline and follow-up headache frequency, pain intensity (VAS/NRS), analgesic use, and adverse events."
"Providers should supply clinical records demonstrating baseline headache days, prior treatments, and objective outcome measures when requesting coverage."

Documentation Required

Document ≥50% diagnostic block response and failed conservative care

Prior diagnostic block response and documentation of prior conservative therapy are associated with better outcomes; documentation showing ≥50% relief after a diagnostic nerve block and failed conservative treatments is expected when appropriate.

"A successful outcome was defined as at least 50% pain relief at six months after C2 DRG pulsed RFA...More people in the success group...had a definite positive response (≥ 50% pain relief) to a previous C2 DRG block."
"Documentation showing prior diagnostic block response (e.g., ≥50% relief after diagnostic nerve block) and prior failure of conservative treatments is supported by reviewed studies..."

Documentation Required

Include prior treatments, trial response (≥50%), and risk discussion in documentation

Suggested documentation elements include a summary of prior conservative treatments tried, evidence of a positive response to temporary trials (commonly defined as ≥50% pain reduction for implantable neurostimulation), and discussion of risks and alternatives.

"Many studies selected patients for permanent implantation after a positive temporary trial, commonly defined as >=50% reduction in pain."
"Documentation of prior conservative treatments, positive response to temporary trials (commonly ≥50% pain reduction) for implantable neurostimulation...are elements emphasized by the evidence base."

Documentation Required

Require diagnostic block and MRI/CT before occipital RFN

Diagnostic blockade of the occipital nerves should precede occipital RFN and MRI/CT should be used to rule out other etiologies prior to RFN; document imaging and diagnostic block results.

"Diagnostic blockade of the occipital nerves should precede the use of RFN."
"Before RFN...other possible etiologies should be ruled out through either magnetic resonance imaging (MRI) and/or computerized tomography (CT) imaging."

Documentation Required

Document consent, governance, audit, and outcomes for transcutaneous SON use

For transcutaneous supraorbital nerve (SON) stimulation, NICE recommends documenting informed consent, clinical governance notification, audit and outcomes data, and patient selection and outcomes (frequency, severity, QoL, medication changes, complications) when used under special arrangements.

"Clinicians wanting to do transcutaneous electrical stimulation of the SON...should inform the clinical governance leads...give people clear written information...audit and review clinical outcomes of everyone having the procedure."
"The evidence for preventing migraine is inadequate in quality. So, for preventing migraine, this procedure should only be used in the context of research."

Documentation Required

Document LA policy retirement and state fee-schedule notes

When determining coverage for Louisiana members, document the policy retirement effective 04/01/2026 and any state fee-schedule considerations (eg, A4540 not on LA Medicaid Fee Schedule) relevant to the claim.

"Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026."
"HCPCS A4540 is not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program."

Denial Risk

Denial risk for procedures deemed unproven/not medically necessary

Procedures listed as unproven and not medically necessary for ON/headache indications (eg, GONB outside malignancy, neurostimulation, occipital neurectomy, RFA, rhizotomy, decompression) may be denied when billed for those indications.

"The following are unproven and not medically necessary for diagnosing and/or treating occipital neuralgia or headaches...Injection of local anesthetics and/or steroids, used as greater occipital nerve blocks; Neurostimulation or electrical stimulation; Occipital Neurectomy; ... Radiofrequency ablation (thermal or pulsed) or denervation; ... Surgical decompression of the greater occipital nerve."

Denial Risk

Denial risk for chronic preventive use of GONB due to limited evidence

Insufficient or low-quality evidence for chronic or long-term use of repeated GONB increases the likelihood of denial for chronic preventive indications without high-quality supporting data.

"Little to no evidence meeting inclusion criteria was found around benefit of chronic use of this therapy."
"The overall quality of the body of evidence remained rated as low...There is little to no evidence that meets the inclusion criteria that found a benefit for chronic therapy use."

Denial Risk

Denial risk when surgical approach lacks comparative evidence

Insufficient evidence to prefer one surgical approach (neurolysis vs neurectomy) over another may lead to denials if submitted without strong supporting documentation or prior failed conservative therapy.

"No RCTs were identified...all were level IV, low-quality evidence...there was insufficient evidence to recommend one treatment method over the other."

Denial Risk

Denial risk for implantable devices with low evidence and high complication rates

Procedures with low-quality evidence and high complication rates (eg, ONS for cluster headache) are at higher risk for noncoverage or denial when evidence of effectiveness is insufficient or when complication risks are significant.

"ONS evidence is low-quality with risk of complications that may require additional surgery."
"Complications of ONS included...infection (2%-27%)...For infections and certain other complications, up to 27% of stimulators needed to be surgically removed or replaced."

Denial Risk

Clinical uncertainty and complication-related denial risk

High complication and device removal rates (reported up to ~27%) and very low-quality evidence for some indications (eg, ONS for chronic cluster headache) may justify denial where clinical benefit is uncertain.

"Up to 27% of stimulators needed to be surgically removed or replaced."
"The body of evidence...was small in size and very low in quality."

Denial Risk

NICE: SON use limited to research/governance arrangements — denial risk if absent

NICE recommends that transcutaneous SON stimulation for prevention be used only in the context of research and that acute use be conducted under special arrangements (clinical governance, consent, audit); lack of these arrangements may result in nonroutine coverage or denial.

"For preventing migraine, this procedure should only be used in the context of research."
"For treating acute migraine...this procedure should only be used with special arrangements for clinical governance, consent, and audit or research."

Billing Rule

State fee-schedule exclusion: A4540 may not be covered in LA

HCPCS code A4540 is noted as not being on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by Louisiana Medicaid; use of this code for LA members may trigger noncoverage or denial.

"Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program."
"Added notation to indicate HCPCS code A4540 is not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program."

Implied by HTA and systematic review conclusions regarding lack of evidence for chronic use

Failure of conservative therapy and/or diagnostic block response prior to invasive procedures is implied as relevant in literature

Diagnostic block response and conservative therapy prior to invasive procedures: Studies frequently included patients who failed conservative therapy and report that a definite positive response to diagnostic blocks (eg, ≥50% relief) is associated with better outcomes after procedures such as C2 DRG pulsed RFA; documentation of prior conservative treatments and block response is therefore relevant.diagnostic block ≥50%

Based on retrospective and prospective study findings (eg, Lee et al., Guo et al.)

Failure of conservative therapy is typical prior to consideration of invasive or implantable procedures

Failure of conservative therapy typical before invasive/implantable procedures: Systematic reviews and clinical series commonly enrolled patients who had failed conservative therapies prior to PRFT, ONS, PNS, or SCS interventions; noninvasive options (eg, REN, GONB) are usually evaluated earlier in treatment algorithms.

Implied by study populations and HTA reports

Trial of pharmacologic and noninvasive therapies prior to consideration of invasive neurostimulation is recommended by multiple societies

Trial of pharmacologic and noninvasive therapies before invasive neurostimulation: Multiple guideline panels (AHS, VA/DoD, NICE) recommend trying pharmacologic and other noninvasive treatments first; neuromodulatory devices are suggested for patients with inadequate response or intolerance to medications and often within specialist or research settings.

Guideline-supported conservative-first approach

Attempt of appropriate medical therapies prior to invasive neuromodulation or interventional procedures (implied)

Attempt appropriate medical therapies prior to invasive neuromodulation or interventional procedures: NICE and other guideline summaries note usual treatments for migraine include acute and preventive pharmacologic therapies; invasive treatments are reserved for distressing, refractory symptoms after medical therapy—implying an attempt of appropriate medical therapies before invasive interventions.

Implied by NICE guidance on treatment sequencing

Conservative-treatment evidence and guideline synthesis: Multiple systematic reviews, randomized trials, and guideline statements cited in the literature inform conservative and interventional approaches; while exact step counts/durations vary by source, the body of evidence supports trying guideline-recommended medical therapies and documenting prior attempts before considering invasive procedures.

References and HTAs summarized in policy; no discrete mandatory step-therapy durations provided in this excerpt

Long-term frequency guidanceNo established long-term frequency recommended; studies vary and long-term preventive use evidence is limited

Frequency limits — general note

Frequency limits — none statedNo explicit procedural frequency limits are stated in this excerpt for many interventions

Evidence implicationLack of standardized frequency reflects heterogeneity of study protocols and insufficient long-term data

RecommendationRefer to specific trial protocols or payer guidance when determining allowable frequency

Pulsed radiofrequency procedures — frequency

PRF frequency guidance — none explicitNo explicit repeat-frequency limits for pulsed radiofrequency procedures are specified in this excerpt

Observed study intervalsSome studies report single treatments with follow-up out to months/years; durability varies by study (Luo et al. 2018; Ertilav et al. 2024)

Clinical implicationRepeat PRF sessions and timing should follow clinical judgment and published study protocols due to limited standardized guidance

Occipital radiofrequency neurotomy — frequency

Occipital RFN frequency limits — none explicitThe policy notes diagnostic blockade should precede RFN and that several studies documented up to six months of relief, but does not set explicit limits on repeat RFN frequency

Imaging and diagnostic prerequisitesMRI/CT should be used to rule out other etiologies prior to RFN; diagnostic occipital nerve block recommended before RFN

Evidence on durabilitySeveral studies document pain relief lasting up to six months; longer-term repeat-session guidance is not established

Documentation Required

Document US or CT guidance for GONB/PRF/SPG procedures when used

Some studies of GONB, PRF, and SPG procedures used ultrasound or CT guidance for needle/electrode placement; document the guidance modality used in the procedural note.

"Tanyel et al. ... inserted under US-guidance..."
"Fang et al. ... CT guided PRFT of SPG."

Documentation Required

CT/US guidance may be used for SPG PRFT and supraorbital PRF

CT or ultrasound guidance may be used for pulsed radiofrequency treatments (PRFT) of the SPG and supraorbital PRF per study reports; document imaging guidance when performed.

"Fang et al. conducted...CT guided PRFT of SPG..."

Documentation Required

Obtain and document MRI/CT before occipital RFN

MRI and/or CT should be performed prior to occipital radiofrequency neurotomy to exclude other etiologies; imaging should be documented though it is not diagnostic for occipital neuralgia.

"Before RFN of the occipital nerves, other possible etiologies should be ruled out through either MRI and/or CT imaging. Imaging is not itself a diagnostic for ON."

Documentation Required

Consider neuroimaging for first cluster headache episode; document discussion

Discuss and document neuroimaging considerations for first presentations of cluster headache as part of diagnostic evaluation and clinical decision-making.

"Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist."

Note

Imaging guidance per guidelines — no additional explicit requirements in excerpt

Referenced best-practice guidelines and consensus documents may include imaging guidance recommendations, but this excerpt contains no explicit mandatory imaging requirements beyond those noted for RFN.

"Referenced best practice guidelines (e.g., LEARN) and consensus documents may include imaging guidance, but no explicit imaging requirement is present in this fragment."

The policy notes that for thermal (nonpulsed) percutaneous RFA there were no RCTs or systematic reviews identified and that the literature volume is insufficient to permit a full evidence assessment, supporting a not‑covered/ investigational interpretation.

Surgical neurectomy and nerve decompression procedures lack high‑quality trial data and therefore are listed among interventions that are not supported as medically necessary for routine treatment of headaches or occipital neuralgia.

ONS-related not‑coverage considerations reference very low quality evidence, high complication and device removal rates in some series, and lack of robust controlled studies—factors that support exclusion from routine coverage.

The VA/DoD guideline (2023) finds insufficient evidence to recommend for or against many forms of neuromodulation for migraine, a position that may inform noncoverage for routine use in absence of stronger evidence.

Repeated not‑covered entries mirror the policy's retirement note and state‑specific coverage implications; inclusion of duplicate placeholders emphasizes the broad set of interventions the policy characterized as not medically necessary for ON/headache indications.

HCPCS code A4540 is noted in the policy history as not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by Louisiana Medicaid; this state fee schedule exclusion can affect reimbursement for devices billed with that HCPCS code.

Clinical actionIf MIDAS score ≥ 6, discussion with a provider is recommended (National Headache Foundation, 2018)

MSQ (Migraine‑Specific Quality of Life Questionnaire)

MSQ — definitionMigraine-Specific Quality of Life Questionnaire: self-report measure assessing migraine-related quality of life across role, emotional, and social functioning (14 items)

Scoring formatItems rated on a 6-point Likert scale from 1 (very poor) to 6 (very good)

Use in studiesUsed as an outcome measure in longer-term neuromodulation trials (eg, SCS studies capture MSQ changes)

Neurectomy

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

Surgical contextStudied for occipital neuralgia and included among various surgical options (eg, dorsal nerve root section, decompression)

Evidence noteLong-term efficacy not established in well‑designed clinical trials per policy summary

Rhizotomy

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

Procedural examplesPartial posterior rhizotomy and cervical dorsal rhizotomy have been described for occipital neuralgia/cervicogenic headache

Evidence noteAvailable evidence insufficient to conclude long‑term effectiveness; further trials needed

GONB — definition

GONB — definitionInjection of local anesthetic with or without corticosteroid around the greater occipital nerve for diagnostic or therapeutic purposes in headache disorders

Guidance on useUsed both diagnostically and therapeutically; trial regimens and frequency vary across studies (single, series, or monthly maintenance)

Imaging/guidanceUltrasound guidance is commonly used in trials for GONB (distal and proximal approaches reported)

Migraine trigger‑site surgery / neuroplasty

Migraine trigger‑site surgery / neuroplasty — definitionSurgical procedures targeting extracranial nerves and/or arterial structures implicated as peripheral triggers of migraine; includes nerve decompression, neurectomy, or related approaches

Evidence summarySome meta-analyses report substantial benefit in selected studies, but overall heterogeneity and limited RCT data reduce certainty

RecommendationFurther rigorous trials needed to define role and long-term outcomes

Pulsed Radiofrequency (PRF)

Pulsed Radiofrequency (PRF) — definitionA non‑ablative form of radiofrequency neuromodulation that delivers intermittent pulses of radiofrequency energy, reported to have a better safety profile than thermal RFA

Clinical useUsed for occipital, C2 DRG, supraorbital and SPG targets in studies with variable durations of benefit

Evidence noteSome RCTs and prospective studies report medium-term benefit; well‑designed larger trials needed

Thermal (nonpulsed) Radiofrequency Ablation (RFA)

Thermal RFA — definitionConventional continuous radiofrequency producing neuro‑destructive lesions (non‑pulsed)

Evidence statusPolicy notes limited peer‑reviewed literature and insufficient RCT evidence for nonpulsed thermal RFA for occipital neuralgia

Safety considerationsThermal RFA may be associated with higher complication rates (eg, neuritis, deafferentation pain) compared with pulsed techniques

PRF / PRFT / PRFN

PRF/PRFT/PRFN — termPulsed radiofrequency treatment (abbreviated PRF/PRFT/PRFN)

Clinical findingsStudies report varying efficacy across neuropathic and headache conditions with some durable responses over months to years in small series

GuidanceProcedural guidance (eg, CT or US) may be used depending on target (SPG, supraorbital, occipital)

REN — definition

REN — definitionRemote electrical neuromodulation (REN): a noninvasive device‑based stimulation modality evaluated in randomized trials for migraine prevention/treatment

Evidence exampleRandomized multicenter trial (Tepper et al.) enrolled 248 participants showing reductions in migraine days and higher responder rates versus placebo

Regulatory noteDevices used for electrical stimulation are regulated via FDA 510(k) or De Novo pathways (eg, Nerivio) — informational for device-based therapies

ONS — Occipital Nerve Stimulation

ONS — definitionOccipital nerve stimulation (ONS): implantable peripheral neurostimulation therapy often preceded by a temporary trial before permanent implantation

Evidence and risksStudies show variable responder rates and notable complication rates including infection and lead migration; evidence quality often low to very low

Trial requirementMany studies selected patients for permanent implantation after a positive temporary trial (commonly ≥50% reduction)

ONS — chronic cluster headache

ONS for chronic cluster headache — contextInvasive neuromodulation with implanted stimulators targeting occipital nerves used for refractory chronic cluster headache; evidence base is small and very low quality

Outcomes and complicationsReported responder rates vary (41%–90% achieving ≥50% decrease in attacks); infection and device removal rates reported up to 27% in some series

RecommendationUse generally considered in specialized/tertiary centers and often within research or with governance/audit arrangements

SPG stimulation

SPG stimulation — definitionSphenopalatine ganglion (SPG) stimulation: implanted stimulation approach shown in RCT to provide acute pain relief for chronic cluster headache

Evidence exampleRandomized sham‑controlled trial (Goadsby et al. 2019) showed greater pain relief at 15 minutes vs sham (62.5% vs 38.9%)

Safety noteSerious adverse events related to implantation have been reported and further research is needed

eTNS / tONS

eTNS / tONS — definitionExternal transcutaneous trigeminal or occipital nerve stimulation devices used noninvasively for preventive treatment of migraine (eg, Cefaly device)

Usage parameterseTNS preventive sessions commonly ~20 minutes daily; acute sessions often 1–2 hours per device labeling and NICE description

Evidence notePilot and randomized trials show preventive benefit in small/low-quality studies; further RCTs required

Transcutaneous electrical stimulation of the SON / eTNS

Transcutaneous SON stimulation — definitionTranscutaneous electrical stimulation of the supraorbital nerve (SON/eTNS): noninvasive stimulation using a headband/electrode applied to the forehead

ApplicationApplied for acute treatment (1–2 hours) and for prevention (~20 minutes); device is self‑administered

NICE governanceNICE recommends use with special arrangements for governance, consent, audit/research for prevention or when evidence is limited

RFA and electrical stimulation — device/regulatory notes

Device product/regulatory framingRFA and electrical stimulation procedures use FDA‑regulated devices; RFA generators/probes (product codes GXD/GXI) and electrical stimulation devices (product codes GZF, GZB, PCC)

Regulatory pathwaysElectrical stimulation devices may have 510(k) clearance or De Novo designation (eg, Nerivio De Novo) — informational

ImplicationDevice regulatory status is informational and does not, by itself, determine coverage or medical necessity

MIDAS — (duplicate definition)

MIDAS — duplicate definition noteMigraine Disability Assessment Test (MIDAS): referenced as a defined term in the policy definitions section

PurposeMeasures disability from headaches; used in outcome assessment and trial reporting

Score bands repeated0–5 little/no; 6–10 mild; 11–20 moderate; 21+ severe

MSQ — (duplicate definition)

MSQ — duplicate definition noteMigraine‑Specific Quality‑of‑Life Questionnaire (MSQ) defined in policy; assesses role, emotional, social functioning

Format14 items rated on 6‑point Likert scale

UseReported in neuromodulation studies as quality‑of‑life endpoint