Subject:
Greater Occipital Nerve Block
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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CMM-402: Greater Occipital Nerve Block
| CMM-402.1: Definitions |
| CMM-402.2: General Guidelines |
| CMM-402.3: Indications |
| CMM-402.4: Non-Indications |
| CMM-402.5: Procedure (CPT®) Codes |
CMM-402.1: Definitions
Red flags indicate comorbidities that require urgent/emergent diagnostic imaging and/or referral for definitive diagnosis and treatment.
Behavioral yellow flags are defined as an active or history of substance abuse, depression, dissatisfaction with work, job disability, or anxiety diagnosis.
Clinically meaningful improvement is a global assessment showing at least 50% improvement, or pain relief is defined as a two (2) point drop in VAS pain scale where 10 is the worst pain imaginable and 0 is no pain at all.
Policy:
[INFORMATIONAL NOTE: For electrical stimulation of the occipital nerve, please refer to a separate medical policy on Occipital Nerve Stimulation for Intractable Migraine Pain (Policy # 060) in the Surgery Section of this database.
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-402.2: General Guidelines
† A complete headache history must be performed which shows that other primary causes of severe headaches (including the presence of any red flags) have been considered.
† For the purposes of this guideline, red flags are diagnostic considerations with secondary causes of severe headache.
† Presence of any of the following are considered to be red flags and the request for greater occipital nerve block(s) should go to medical review:
® Multiple sclerosis associated headache, trigeminal neuralgia in a young adults
® Intracranial infection with fever, altered consciousness or personality change in IVD use or TB
® Stroke with new onset muscle weakness, sensory changes, alteration in speech
® Malignant hypertension
CMM-402.3: Indications
The performance of the first greater occipital nerve block for occipital neuralgia is considered medically necessary when all of the following are met:
† Absence of red flag conditions
† Diagnosis of occipital neuralgia as evidenced by both of the following:
® Paroxysmal stabbing pain, with or without aching between attacks, in the distribution of the nerve
® Tenderness over the affected nerve
† Evidence of a comprehensive headache evaluation with consideration of alternative causes such as any of the following:
® Exertional headache
® Migraine with or without aura
® Medication overuse headache
The performance of the second and subsequent greater occipital nerve block(s) for recurrent occipital neuralgia are considered medically necessary when all of the following are met:
† Absence of red flag conditions
† Significant improvement after first injection
† Self-care is attempted at headache onset and ineffective and includes both of the following:
® Anti-inflammatory medications or muscle relaxants
® Rest, massage, or heat
† Confirmed diagnosis of recurrent occipital neuralgia as evidenced by tenderness to palpation over the greater occipital nerve
† Evidence of both of the following for patients with chronic pain where there has been continuous opiate usage for 3 months or longer:
® Co-management of behavioral health and medical conditions
® A plan to address potential opiate overuse or abuse
CMM-402.4: Non-Indications
† Greater occipital nerve blocks are not considered medically necessary for any of the following:
® When performed in conjunction with additional pain management procedures [cervical facet injections/medial branch blocks (CPT®64490, 64491, and 64492) or trigger point injections (CPT®20552)] planned on the same day unless there has been recent discontinuation of anticoagulant therapy for the purpose of interventional pain management with injections
® More than 6 greater occipital nerve blocks in the same anatomic areas in the past 12 months
® Less than 4 weeks since the last occipital nerve block, cervical trigger point injection, or cervical facet injection/medial branch block
† Occipital nerve ablation by any method is considered investigational.
CMM-402.5: Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor. |
CPT® | Code Description/Definition |
64405 | Injection, Anesthetic Agent; Greater Occipital Nerve |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. |
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Greater Occipital Nerve Block
Occipital Nerve Block
Nerve Block, Occipital
Occipital Nerve Ablation
References:
1. Siberstein S. Evaluation of the Headache in Patient. Clinician's Manual on Migraine. Philadelphia: Current Medicine, Inc.; 2002:Page 9.
2. Balmaceda C., Rossi, J. Detecting Potentially Life-Threatening Headache Syndromes. J Crit Illn. 2003;18:23-30.
3. Peters K. S. Secondary headache and head pain emergencies. Prim Care. Jun 2004;31(2):381-393, vii.
4. Ashkenazi A., Matro, R., Shaw, J. W., et al. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study. J Neurol Neurosurg Psychiatry. Apr 2008;79(4):415-417.
5. Krymchantowski A. V., Silva, M. T., Barbosa, J. S., et al. Amitriptyline versus amitriptyline combined with fluoxetine in the preventative treatment of transformed migraine: a double-blind study. Headache. Jun 2002;42(6):510-514.
6. Spira P. J., Beran, R. G. Gabapentin in the prophylaxis of chronic daily headache: a randomized, placebo-controlled study. Neurology. Dec 23 2003;61(12):1753-1759.
7. Silberstein S. D., Lipton, R. B., Dodick, D. W., et al. Efficacy and safety of topiramate for the treatment of chronic migraine: a randomized, double-blind, placebo-controlled trial. Headache. Feb 2007;47(2):170-180.
8. De Felice M., Porreca, F. Opiate-induced persistent pronociceptive trigeminal neural adaptations: potential relevance to opiate-induced medication overuse headache. Cephalalgia. Dec 2009;29(12):1277-1284.
9. Ghiotto N., Sances, G., Galli, F., et al. Medication overuse headache and applicability of the ICHD-II diagnostic criteria: 1-year follow-up study (CARE I protocol). Cephalalgia. Feb 2009;29(2):233-243.
10. Pageler L., Savidou, I., Limmroth, V. Medication-overuse headache. Curr Pain Headache Rep. Dec 2005;9(6):430-435.
11. Lake A. E., 3rd. Medication overuse headache: biobehavioral issues and solutions. Headache. Oct 2006;46 Suppl 3:S88-97.
12. Dubois M. Y., Livovich, J., Fletwood, J., et al. Incompetence, drug diversion or pain management? Trying to draw the line. Pain Med. Mar 2002;3(1):73-77.
13. Fishbain D. A., Cutler, R. B., Rosomoff, H. L., et al. Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering? Clin J Pain. Nov-Dec 2004;20(6):399-408.
14. Giordano J., Schatman, M. E. A crisis in chronic pain care: an ethical analysis. Part three: Toward an integrative, multi-disciplinary pain medicine built around the needs of the patient. pain Physician. Nov-Dec 2008;11(6):775-784.
15. Kahan M., Srivastava, A., Wilson, L., et al. Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician. Sep 2006;52(9):1081-1087.
16. Tacci J. A., Webster, B. S., Hashemi, L., et al. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. J Occup Environ Med. Nov 1998;40(11):958-963.
17. Ferrari A., Leone, S., Tacchi, R., et al. The link between pain patient and analgesic medication is greater in migraine than in rheumatic disease patients. Cephalalgia. Jan 2009;29(1):31-37.
18. Bovim G., Fredriksen, T. A., Stolt-Nielsen, A., et al. Neurolysis of the greater occipital nerve in cervicogenic headache. A follow up study. Headache. Apr 1992;32(4):175-179.
19. Gille O., Lavignolle, B., Vital, J. M. Surgical treatment of greater occipital neuralgia by neurolysis of the greater occipital nerve and sectioning of the inferior oblique muscle. Spine (Phila Pa 1976). Apr 1 2004;29(7):828-832.
20. First Coast Service Options, Inc. Local coverage determination (LCD) for peripheral nerve blocks (L33933).
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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