A4540 — Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Diagnosis documentation consistent with malignancy involving the head and neck when claiming coverage for GONB or occipital nerve ablation (examples of relevant ICD-10 codes listed in policy: C76.0 Malignant neoplasm of head, face and neck; G89.3 Neoplasm related pain (acute) (chronic)). For procedures targeting headache/occipital neuralgia generally, use of established diagnostic criteria: documentation that diagnosis criteria of the International Headache Society (IHS) and/or Cervicogenic Headache International Study Group were applied (policy notes these criteria are currently used for diagnosis). When considering radiofrequency neurotomy (per ASPN best practices): 'Diagnostic blockade of the occipital nerves should precede the use of RFN.' (document evidence of diagnostic blockade and response required prior to RFN per guidance). Prior imaging before 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.' (document MRI/CT results when applicable). Procedure documentation: operative/procedure note documenting the injected agent (local anesthetic and/or steroid) or neurolytic agent, laterality, technique, guidance modality (if used), and immediate procedural outcome and complications. Patient-reported outcome measures where used or recommended in studies/guidelines: MIDAS, MSQ, VAS/NRS, headache diaries (policy defines MIDAS and states: 'If the MIDAS score is 6 or more, discussion with a provider is necessary'). Documentation of prior conservative therapy trials may be relevant based on clinical context and guideline recommendations (policy repeatedly references failure of conservative/medical therapy as context for interventional options; while not stated as an absolute coverage prerequisite, clinical records showing prior medical management are informative). Informed consent and documentation of discussion of alternative therapies and risks, especially for procedures with limited evidence or higher complication rates (implied by policy discussion of risks and guideline recommendations). NICE (2022): Clinicians wanting to do transcutaneous electrical stimulation of the SON for acute treatment of migraine should inform the clinical governance leads in their healthcare organization, give people and their families/carers clear written information (including NICE information for the public), and ensure understanding of procedure safety, efficacy, and uncertainties. NICE (2022): Clinicians should audit and review clinical outcomes of everyone having the procedure; main efficacy and safety outcomes can be entered into NICE's interventional procedures outcomes audit tool. NICE (2022): Healthcare organizations should ensure systems are in place to support clinicians to collect and report data on outcomes and safety and regularly review these data. NICE (2022): Patient selection should usually be done by clinicians (including clinical nurse specialists) with expertise in managing migraine. NICE (2022): Studies / use in research should describe whether the procedure is used for treatment or prevention; include details of patient selection, intensity, duration and frequency of use; outcome measures should include number and severity of migraine episodes, quality of life (short and long term), any changes in medication and management of subsequent attacks, and development of any complications after starting treatment. European Headache Federation: use in medically intractable syndromes should be performed at tertiary headache centers and/or as part of a valid study (implying documentation of refractory status and study/center participation). UnitedHealthcare administrative instruction: When deciding coverage, reference the member specific benefit plan document; in absence of NCD/LCD, Medicare Advantage Organizations may create coverage determinations using objective evidence-based rationale.
Key Coverage Criteria
- Injection of local anesthetics and/or steroids used as greater occipital nerve blocks (GONBs) — proven and medically necessary for treating pain due to malignancy involving the head and neck. Occipital nerve ablation (destruction by neurolytic agent) — proven and medically necessary for treating pain due to malignancy involving the head and neck. [...]
- Initial use of the Nerivio®remote electrical neuromodulation (REN) device for the treatment of migraine is consideredmedically necessaryin individuals who meet ALL of the following criteria:
- Eight years of age or older;and
- Six-month history of headaches that meet International Classification of Headache Disorders (ICHD 3-beta) diagnostic criteria for migraine with or without aura;and
- Meets one of the following two criteria:Nerivio is used to treat acute migraine;orNerivio is used to prevent migraine for individuals with 6 to 24 headache days (defined as a calendar day with headache regardless of severity or duration) per 28-day period in each of the 3 months preceding use of Nerivio.
- Nerivio is used to treat acute migraine;or
6 Active Policies
ANTHEM-DME.00011 — DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
ANTHEM-CG-MED-100 — CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine
UHC-POL-occipital-neuralgia-headache-treatment — Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)
UMR-POL-UMR-occipital-neuralgia-headache-treatment — Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache)
Related Codes
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