64772
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
7.64
Facility
$516.38
Non-Facility
$516.38
Documentation Required
- Clinical evaluation documenting the suspected migraine trigger site(s).
- Documentation of diagnostic botulinum toxin injection(s) used to localize trigger site(s) and results demonstrating provocation/relief consistent with the identified site(s).
- Operative plan specifying the targeted nerve segments, muscles, fascia, and/or vessels corresponding to the identified trigger site(s).
- Clinical documentation of migraine diagnosis meeting ICHD‑II criteria.
Key Coverage Criteria
- Migraine headache is a recurrent disorder with attacks typically lasting 4 to 72 hours.
- Typical migraine features include unilateral location, pulsating quality, moderate to severe intensity, and associated symptoms such as nausea, photophobia, and/or phonophobia.
- Surgical deactivation of trigger sites as a proposed treatment for migraine headaches.
- Patients whose migraines are thought to arise from inflammation or irritation of trigeminal nerve branches caused by surrounding musculature, bony foramina, or fascial bands.
- Surgical treatment of migraine when one or more migraine trigger sites (frontal, temporal, rhinogenic, occipital) have been identified in the patient.
- Trigger site identification must be based on clinical evaluation and diagnostic botulinum toxin injections demonstrating the site(s) provoking the patient's migraines.
6 Active Policies
ANTHEM-SURG.00096 — SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
BCBSIL-SUR712.031 — Surgical Deactivation of Headache Trigger Sites
BCBSMT-SUR712.031 — Surgical Deactivation of Headache Trigger Sites
BCBSNM-SUR712.031 — Surgical Deactivation of Headache Trigger Sites
BCBSOK-SUR712.031 — Surgical Deactivation of Headache Trigger Sites
Related Codes
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