Criteria
Coverage is subject to the specific terms of the member's benefit plan.
When ordered by a licensed clinician, Nerivio may be considered medically necessary for individuals 12 years of age or older when
ANY
of the following conditions have been met:
-
Individual is in acute onset of migraine headache with or without aura;
or
-
Individual has onset of aura associated with migraine headache;
or
-
Individual has chronic migraines;
or
- Individual is utilizing the REM for preventive treatment of migraine;
AND
Individual is experiencing
ANY
of the following:
-
Adverse effects or non-optimal performance from guideline-directed migraine medication regimen;
or
- Has a medical condition that contraindicates taking migraine medications.
Nerivio not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Code