S0020 — Injection, bupivicaine hydrochloride, 30 ml
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Use validated outcome measures to document change in condition and demonstrate net health outcome (e.g., length of life, quality of life, functional status).
- Documentation that patient meets ICHD‑II diagnostic criteria for chronic migraine.
- Record of chronic migraine duration (≥3 months).
- 28‑day baseline headache diary or equivalent documentation used to confirm diagnosis.
Key Coverage Criteria
- None — sphenopalatine ganglion (SPG) blocks are considered experimental, investigational and/or unproven for all headache indications.
- Migraine (episodic migraine, with or without aura)
- Tension-type headache
- Chronic migraine defined as headache on ≥15 days per month for >3 months with migraine features on ≥8 days per month
- Tension-type headache: presence of at least two of the following—bilateral location, non-pulsating pain, mild-to-moderate intensity, not aggravated by physical activity; duration 30 minutes to 7 days; not accompanied by nausea, vomiting, photophobia, or phonophobia.
- Cluster headache: severe unilateral orbital, supraorbital, and/or temporal pain often with ipsilateral autonomic signs (e.g., rhinorrhea, eyelid edema or ptosis).
5 Active Policies
BCBSIL-MED205.039 — Sphenopalatine Ganglion Block for Headache
BCBSMT-MED205.039 — Sphenopalatine Ganglion Block for Headache
BCBSNM-MED205.039 — Sphenopalatine Ganglion Block for Headache
BCBSOK-MED205.039 — Sphenopalatine Ganglion Block for Headache
MED205.039 — Sphenopalatine Ganglion Block for Headache
Related Codes
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