Peripheral Nerve Destruction for Pain Conditions - (0525)

Cigna covers peripheral nerve destruction (radiofrequency ablation or glycerol rhizotomy) only for trigeminal neuralgia that is refractory to other treatments, while percutaneous cryoablation of distal/peripheral lower‑extremity nerves is considered experimental and ablation by cryo, laser, electrical, chemical or RF is explicitly not covered for a wide list of pain conditions (e.g., SI‑joint, knee/hip/shoulder/foot pain, headache/occipital neuralgia, intercostal neuralgia, CRPS, nerve entrapments, peripheral neuropathy). Claims must use applicable covered diagnosis/procedure codes (e.g., CPT 61790/61791/64600/64605/64610 when criteria are met) and include documentation that trigeminal neuralgia was refractory to alternative treatments; the policy cites insufficient evidence for ablation in cervicogenic/occipital headache and many other peripheral pain conditions.

"Peripheral nerve destruction using radiofrequency ablation or glycerol rhizotomy is considered medically necessary for treatment of trigeminal neuralgia refractory to other alternative treatments (e."