CMM-402: Greater Occipital Nerve Block

Greater occipital nerve block (CPT 64405) is medically necessary for the first injection for occipital neuralgia and for repeat injections when criteria are met, but occipital nerve ablation is not covered and same‑day additional pain procedures are generally excluded (unless a documented recent anticoagulant discontinuation exception applies), with >6 injections/12 months or injections <4 weeks apart considered not medically necessary. Key requirements: documented absence of red flags and a comprehensive headache evaluation plus diagnostic findings (paroxysmal stabbing pain in the nerve distribution and tenderness) for the first injection; subsequent injections require documented benefit from the first, failed self‑care (anti‑inflammatories or muscle relaxants and rest/massage/heat), confirmation of recurrence, documentation of prior procedure dates to meet frequency limits, and opioid co‑management/plan for patients on chronic opioids ≥3 months.

"Performance of the first greater occipital nerve block for occipital neuralgia is considered medically necessary when all of the following are met: Absence of red flag conditions; Diagnosis of occi..."