UnitedHealthcare® Oxford Clinical Policy OCCIPITAL NEURALGIA AND HEADACHE TREATMENT Policy Number: PAIN 018.21 T2 Effective Date: February 1, 2018 Table of Contents Page Related Policies INSTRUCTIONS FOR USE .......................................... 1 Ablative Treatment for Spinal Pain CONDITIONS OF COVERAGE ...................................... 1 Botulinum Toxins A and B BENEFIT CONSIDERATIONS ...................................... 2 Durable Medical Equipment, Orthotics, Ostomy COVERAGE RATIONALE ............................................. 2 Supplies, Medical Supplies and Repairs/ APPLICABLE CODES ................................................. 3 Replacements DESCRIPTION OF SERVICES ...................................... 4 Electrical Stimulation and Electromagnetic Therapy CLINICAL EVIDENCE ................................................. 4 for Wounds U.S. FOOD AND DRUG ADMINISTRATION ................... 16 REFERENCES .......................................................... 16 Vagus Nerve Stimulation POLICY HISTORY/REVISION INFORMATION ................ 20 INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE Applicable Lines of Business/Products This policy applies to Oxford Commercial plan membership. Benefit Type General benefits package Referral Required No (Does not apply to non-gatekeeper products) Authorization Required Yes1 (Precertification always required for inpatient admission) Precertification with Medical Director Review Required No Applicable Site(s) of Service Office, Outpatient (If site of service is not listed, Medical Director review is required) Special Considerations 1Precertification is required for services covered under the Member's General Benefits package when performed in the office of a participating provider. For Commercial plans, precertification is not required, but is encouraged for out-of-network services performed in the office that are covered under the Member's General Benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered. Occipital Neuralgia and Headache Treatment Page 1 of 20 UnitedHealthcare Oxford Clinical Policy Effective 02/01/2018 ©1996-2018, Oxford Health Plans, LLC BENEFIT CONSIDERATIONS Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable. Essential Health Benefits for Individual and Small Group For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage. COVERAGE RATIONALE Injection of local anesthetics and/or steroids, used as occipital nerve blocks, is proven and medically necessary for treating pain due to malignancy involving the head and neck. Injection of local anesthetics and/or steroids, used as occipital nerve blocks, is unproven and not medically necessary for diagnosing and treating occipital neuralgia or headaches including migraine and Cervicogenic Headaches. There is insufficient evidence that greater occipital nerve blocks can be used as a specific diagnostic test for occipital neuralgia or headaches. The efficacy of local injection therapies for occipital neuralgia or Cervicogenic Headache and other headaches has not been established in well-designed clinical trials. See the policy titled Botulinum Toxins A and B for information regarding the use of botulinum toxin for treatment of headaches. Surgery, including but not limited to the following, is unproven and not medically necessary for treating occipital neuralgia or Cervicogenic Headache. Occipital neurectomy Partial posterior intradural C1-C3 rhizotomy Rhizotomy of C1-C3 spinal dorsal roots Surgical decompression of second cervical nerve root and ganglion Surgical decompression of the greater occipital nerve The available evidence is insufficient to conclude that surgery is an effective treatment for occipital neuralgia or Cervicogenic Headaches. The long-term efficacy of surgical procedures for occipital neuralgia or Cervicogenic Headaches has not been established in well-designed clinical trials. Occipital neurectomy or surgical nerve decompression is unproven and not medically necessary treating headaches. The available evidence is insufficient to conclude that occipital neurectomy or nerve decompression including decompression of the supraorbital, supratrochlear, zygomaticotemporal, or greater occipital nerves is an effective treatment for headaches. The long-term efficacy of these procedures for headaches has not been established in well- designed clinical trials. Radiofrequency ablation (thermal or pulsed) or denervation is unproven and not medically necessary for treating of occipital neuralgia or headaches including migraine, cluster and Cervicogenic Headaches. The available evidence from published studies is not sufficient to conclude that radiofrequency ablation or denervation is an effective treatment for occipital neuralgia or headaches. Well-designed studies are needed to evaluate the potential advantages of radiofrequency ablation for these conditions and to identify which patients would benefit from this procedure. Neurostimulation or electrical stimulation is unproven and not medically necessary for treating of occipital neuralgia or headaches including migraine, cluster and Cervicogenic Headaches. The available studies were limited and had significant methodological flaws, making it difficult to draw conclusions regarding the efficacy of electrical stimulation for the treatment of headaches or occipital neuralgia. There are no well- designed randomized controlled studies in the medical literature comparing neurostimulation to established treatment options or a sham procedure. Studies on larger populations with longer follow-up are needed to establish the benefits of neurostimulation and electrical stimulation for treating these conditions. Occipital Neuralgia and Headache Treatment Page 2 of 20 UnitedHealthcare Oxford Clinical Policy Effective 02/01/2018 ©1996-2018, Oxford Health Plans, LLC DEFINITIONS Cervicogenic Headache: Referred pain perceived in the head from a source in the neck. In the case of Cervicogenic Headache, the cause is a disorder of the cervical spine and its component bony, disc and/or soft tissue elements. (American Migraine Foundation, 2016) APPLICABLE CODES The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. 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. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. CPT Code Description Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline 62281 solutions), with or without other therapeutic substance; epidural, cervical or thoracic 63185 Laminectomy with rhizotomy; 1 or 2 segments 63190 Laminectomy with rhizotomy; more than 2 segments 64405 Injection, anesthetic agent; greater occipital nerve 64553 Percutaneous implantation of neurostimulator electrode array; cranial nerve Percutaneous implantation of neurostimulator electrode array; peripheral