J1110, Injection, dihydroergotamine mesylate, per 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that other intractable severe migraine attacks were unresponsive to analgesics and triptans (example list of triptans provided in policy).
- For Eptinezumab-jjmr (Vyepti): documentation that the member is an adult with migraine and meets criteria per CPB 0970 (referenced by policy).
- For IM ketorolac: documentation that use is short-term (<= 5 days) and for acute migraine diagnosis codes listed in policy (examples: G43.001 - G43.619, G43.B0 - G43.B1, G43.801 - G43.919).
- No documentation requirements are specified in this Appendix section.
Key Coverage Criteria
- Magnesium supplementation for migraine prevention in adults (limited evidence from small RCTs with mixed results; discussed as a possible option).
- IV ketamine infusion combined with magnesium sulfate for chronic intractable cluster headache (case reports showing symptomatic relief; Moisset et al. 2017).
- Intravenous and intranasal ketamine for acute/abortive treatment of migraine (multiple small RCTs, open-label studies and systematic reviews/meta-analyses; potential short-term analgesic benefit reported).
- Inpatient continuous or multi-day ketamine or lidocaine infusion protocols as therapy for refractory chronic migraine (rCM) when other treatments have failed (practice series and pilot studies; Mojica et al. 2021; Schwenk et al. 2021; Ray et al. 2022).
- Transcutaneous supraorbital neurostimulation (tSNS, Cefaly device / extra-cephalic supraorbital TNS) for preventive treatment of episodic migraine (randomized trial evidence suggesting superiority to sham in episodic migraine prevention; Russo & Tessitore 2015; UpToDate summary referencing RCT).
- Intramuscular (IM) ketorolac (Toradol) for acute migraine treatment in adults (RCTs comparing IM ketorolac to other agents showing similar efficacy; Duarte et al. 1992; Shrestha et al. 1996; also supported in ED settings per UpToDate).
1 Active Policy
AETNA-CPB-0462, Headaches: Nonsurgical Management
Related Codes
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