occipital neuralgia and cervicogenic, cluster and migraine headaches

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• Occipital neurectomy • Partial posterior intradural C1-C3 rhizotomy • Rhizotomy of C1-C3 spinal dorsal roots • Surgical decompression of second cervical nerve root and ganglion • Surgical decompression of the greater occipital nerve The available evidence is insufficient to conclude that surgery is an effective treatment for occipital neuralgia or cervicogenic headache. The long-term efficacy of surgical procedures for occipital neuralgia or cervicogenic headache has not been established in well designed clinical trials. Occipital neurectomy or surgical nerve decompression is not medically necessary for the treatment of headaches. The available evidence is insufficient to conclude that occipital neurectomy or nerve decompression including decompression of the supraorbital, supratrochlear, zygomaticotemporal, or greater occipital nerves is an effective treatment for headaches. The long-term efficacy of these procedures for headaches has not been established in well designed clinical trials. Radiofrequency ablation (thermal or pulsed) or denervation is not medically necessary for the treatment of occipital neuralgia or headaches including migraine, cluster and cervicogenic headache. The available evidence from published studies is not sufficient to conclude that radiofrequency ablation or denervation is an effective treatment for occipital neuralgia or cervicogenic headache. Well-designed studies are needed to evaluate the potential advantages of radiofrequency ablation for these conditions and to identify which patients would benefit from this procedure. Neurostimulation or electrical stimulation of the occipital nerve is not medically necessary for the treatment of occipital neuralgia or headaches including migraine, cluster and cervicogenic headache. The available studies were limited and had significant methodological flaws, making it difficult to draw conclusions regarding the efficacy of electrical stimulation for the treatment of cervicogenic headache or occipital neuralgia. There are no randomized controlled studies in the medical literature comparing occipital neurostimulation to established treatment options or a sham procedure. Medicare does not have a National Coverage Determination that addresses the use of injections of local anesthetics or steroids or surgery or neurostimulation or electrical stimulation for the treatment of headaches. Medicare does have a Local Coverage Determination for Nevada that addresses TENS for headaches: Transcutaneous Electrical Nerve Stimulators (TENS) (L11495), accessed July, 2012. The portion of the Local Coverage Determination that applies to headaches is as follows: A transcutaneous electrical nerve stimulator (TENS) is covered for the treatment of patients with chronic, intractable pain or acute post-operative pain who meet the coverage rules listed below. When a TENS unit is used for acute post-operative pain, the medical necessity is usually limited to 30 days from the day of surgery. Payment for more than one month is determined by individual consideration based upon supportive documentation provided by the attending physician. Payment will be made only as a rental. A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months duration), other than post-operative pain. For chronic pain, the medical record must document the location of the pain, the duration of time the Occipital Neuralgia & Headache Page 2 of 24
patient has had the pain, and the presumed etiology of the pain. The pain must have been present for at least three months. Other appropriate treatment modalities must have been tried and failed, and the medical record must document what treatment modalities have been used. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. Examples of conditions for which a TENS unit are not considered to be reasonable and necessary are (not all-inclusive): headache, visceral abdominal pain, pelvic pain, and temporomandibular joint (TMJ) pain. When used for the treatment of chronic, intractable pain, the TENS unit must be used by the patient on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial period will be paid as a rental. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. For coverage of a purchase, the physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time. The physician's records must document a reevaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time, and the results. The physician ordering the TENS unit must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit. For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. http://www.cms.hhs.gov/mcd/search Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services’ Website. BACKGROUND Cervicogenic headache and occipital neuralgia are conditions whose diagnosis and treatment have been gradually refined over the last several years. This terminology has come to refer to specific types of unilateral headache thought to arise from impingement or entrapment of the occipital nerves and/or the upper spinal vertebrae. Compression and injury of the occipital nerves within the muscles of the neck and compression of the second and third cervical nerve roots are generally felt to be responsible for the symptoms, including unilateral and occasionally bilateral head, neck, and arm pain. The criteria for diagnosis of these entities currently include those of the International Headache Society (IHS) and the Cervicogenic Headache International Study Group. Various treatments have been advocated for cervicogenic headache and occipital neuralgia. Oral analgesics and anti-inflammatory agents are effective for some patients, but there is a population of patients who do not experience pain relief with these medications. Local injections, epidural steroid injections, radiofrequency ablation of the planum nuchae, electrical stimulation, rhizotomy, ganglionectomy, nerve root decompression, discectomy and spinal fusion have all been investigated in the treatment of cervicogenic headache and occipital neuralgia. Occipital Neuralgia & Headache Page 3 of 24
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