CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

This policy addresses radiofrequency (RF) neurolysis and pulsed radiofrequency (PRF) therapy for trigeminal neuralgia. RF neurolysis is covered as medically necessary only for individuals with trigeminal neuralgia who have not responded to or cannot tolerate conservative pharmacologic therapy; it is not covered when these criteria are not met. PRF therapy for trigeminal neuralgia is considered not medically necessary and is not covered.

"Radiofrequency (RF) neurolysis is consideredmedically necessaryfor individuals with trigeminal neuralgia who do not respond to or cannot tolerate medical therapy."

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