Anthem Blue Cross Connecticut SURG.00096 Surgical and Ablative Treatments for Chronic Headaches Form

This document addresses surgical and ablative treatments for chronic headaches, such as migraine and tension type headaches, and occipital neuralgia. A variety of procedures are proposed for this purpose and include, for example, identification of nerve trigger points in the forehead and surgically removing muscle tissue from these areas, and closure of a patent foramen ovale. This document does not address nasal or sinus surgery.

Note: Please see the following related documents for additional information:

• SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
• SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

Position Statement

Investigational and Not Medically Necessary:

Surgical treatment for chronic headaches (including but not limited to chronic migraine headache and chronic tension type headache) is considered investigational and not medically necessary. This includes, but is not limited to, the following procedures:

• Resection of musculature, including but not limited to the corrugator supercilii muscle, or any soft tissue from the forehead, periorbital, occipital or other facial or scalp areas; or
• Manipulation or repositioning of any muscle or other soft tissue within these areas; or
• Resection of any portion of the trigeminal nerve or its branches; or
• Closure of patent foramen ovale.

Surgical and ablative treatments of occipital neuralgia are considered investigational and not medically necessary. This includes, but is not limited to, the following procedures for treatment of occipital neuralgia:

• Thermal neurolysis (thermal and cryodenervation);
• Neuroplasty;
• Decompression of the occipital nerves;
• Resection or partial resection of muscle or tissue.