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Remote Electrical Neuromodulation for Migraines (7.01.171)
Effective date
Nov 1, 2026
Identified
Apr 1, 2026
Summary
Blue Shield of California medical policy 7.01.171, Remote Electrical Neuromodulation for Migraines, is effective November 1, 2026, and its policy history lists an annual review that updated the policy statement and literature review. The policy states that remote electrical neuromodulation for acute migraine is considered investigational, while for prevention of migraine it may be considered medically necessary for individuals ages 8 to 17, and for adults 18 and older, when the stated criteria are met. Remote electrical neuromodulation for prevention of migraine outside those criteria is considered investigational.
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What to do
Action · 7 steps
01Already effective November 1, 2026: For preventive use of remote electrical neuromodulation, confirm the patient meets the criteria in the policy.
02For ages 8 to 17, the patient must have headaches that meet the ICHD-3 diagnostic criteria for migraine with or without aura, and 6 to 24 headache days per 28-day period in each of the 3 months preceding use of the device.
03For adults 18 and older, the patient must also have insufficient response, contraindication, or intolerance to 2 or more guideline-recommended preventive headache medications from at least two of these drug classes: anticonvulsants, antihypertensives, antidepressants, and CGRP inhibitors.
04For continued use, the policy requires compliance with ongoing use and documentation of clinical benefit, which may include a clinician attestation; assessment for clinical benefit is reasonable after a minimum of 8 to 12 weeks for preventive treatment.
05Remote electrical neuromodulation for acute migraine is considered investigational under this policy.
06Provide the following documentation for clinical review: history and physical and/or consultation notes including clinical findings (pertinent symptoms and duration), comorbidities, the reason for the device (prophylaxis versus acute treatment), past and present diagnostic testing and results, and prior conservative treatments with duration and response.
07Include other pertinent multidisciplinary notes or reports, such as psychological or psychiatric evaluation, physical therapy, or multidisciplinary pain management, when applicable.
Codes mentioned
A4540
Original notice
Remote Electrical Neuromodulation for Migraines (7.01.171)
blueshieldca.com · Always check the source before changing claims.