![]() Epidural steroid injection, and radiofrequency ablation for the treatment of cervicogenic headache and neck pain.Combination benztropine mesylate (Cogentin) / diphenhydramine (Benadryl) / promethazine HCl (Phenergan) cocktail with intravenous haloperidol (Haldol) or droperidol (Inapsine) infusion for the treatment of status migrainosus because the effectiveness of this combination for this indication has not been established.Photo-biomodulation, and the Reed procedure (combined occipital and supraorbital neurostimulation) for the treatment of chronic headaches (e.g., cluster, migraine, and tension headaches).Percutaneous bioelectric current stimulation.Ketamine infusion combined with magnesium.Blockade / stimulation of the sphenopalatine ganglion and its branches.Anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies eptinezumab, erenumab, and fremanezumab.The following interventions for the treatment of cluster headache (not an all-inclusive list): Tx360 nasal applicator (spheno-palatine ganglion blockade).Transcranial magnetic stimulation (e.g., SpringTMS).Supraorbital transcutaneous stimulation (for migraines and other types of headaches).Nerivio (remote electrical neuromodulation ).Memantine (for prophylaxis of migraine).Melantonin (for prophylaxis of migraine).Lidocaine injections into the supraorbital nerve and supratrochlear nerve, supraorbital nerve and supratrochlear nerve blocks.Intravenous nalbuphine or other opioid agonist-antagonists.Intravenous aspirin (lysine acetylsalicylate).Intramuscular nalbuphine or other opioid agonist-antagonists.Chemodenervation with P2G (phenol-glycerine-glucose) for migraine prophylaxis.The following interventions for the management of members with migraines (not an all-inclusive list):.Measurement of serum and/or cerebrospinal fluid (CSF) levels of tumor necrosis factor-alpha for intractable migraine or cluster headache.Intravenous (IV) DHE for members with inadequately controlled intermittent migraine attacks who do not have an active, prolonged, and debilitating (i.e., lasting more than 72 hours) headache at the time of admission.Intravenous (IV) DHE for all other types of headache not included in Section I.Caffeine citrate infusion for the treatment of post lumbar puncture headache when the member is unable to take caffeine orally.Īetna considers the following nonsurgical interventions for headaches experimental and investigational because the effectiveness of these approaches has not been established:.Intramuscular (IM) and intravenous (IV) steroids for the treatment of acute migraines.See CPB 0970 Eptinezumab-jjmr (Vyepti) for coverage criteria for Vyepti. Eptinezumab-jjmr (Vyepti) for the preventive treatment of migraine in an adult member when the criteria are met.Intramuscular (IM) ketorolac tromethamine (Toradol) for the short-term (less than or equal to 5 days) management of acute migraine.Treatment of medication overuse headache in the inpatient setting. ![]() Treatment of cluster headache attacks that do not respond to oxygen or triptans in the emergency room, hospital, or urgent care setting or.Treatment of other intractable severe migraine attacks that are unresponsive to analgesics and triptans (e.g., Almotriptan, Amerge, Axert, Frova, Imitrex, Imitrex nasal spray, Maxalt, Maxalt MLT, Onzetra Xsail, Relpax, Sumavel, Treximet, zolmitriptan, zolmitriptan ODT, Zomig, and Zomig ZMT) in the emergency room, hospital or urgent care setting or.Treatment of status migrainosus (i.e., a debilitating migraine lasting more than 72 hours) in the emergency room, urgent care or hospital setting or.Intravenous (IV) administration of dihydroergotamine (DHE) medically necessary for the following indications: This Clinical Policy Bulletin addresses nonsurgical management of headaches.Īetna considers the following nonsurgical interventions for headaches medically necessary when criteria are met: Number: 0462 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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