CMM-403: Neurolytic Agent Creation of Lesion

Covered: Neurolytic creation of a lesion using thermal radiofrequency, glycerol, or alcohol is medically necessary only for trigeminal neuralgia (not for other diagnoses) when strict criteria are met; procedures not meeting criteria are not covered, with limits of one invasive procedure per date of service and one neurolytic procedure per six months. Key requirements: documentation of recurrent severe unilateral shock‑like facial/jaw pain with diagnosis and consideration of alternatives, MRI excluding intracranial mass or MS (or documentation that any causative condition is being treated), prior adequate trial of or contraindication to neuropathic pharmacotherapy, use of fluoroscopic or CT guidance, and for repeat procedures ≥6 months of pain benefit after the prior neurolysis.

"This guideline only applies to the neurolytic creation of a lesion for trigeminal neuralgia and not for other conditions."