CMM-403: Neurolytic Agent Creation of Lesion

Percutaneous neurolytic lesioning (thermal radiofrequency, glycerol, or alcohol) for trigeminal neuralgia is covered when strict diagnostic, imaging, prior‑therapy, and procedural criteria are met, and is not medically necessary if performed without fluoroscopic/CT guidance or with other neurolytic methods. Key requirements include documented trigeminal neuralgia with alternatives considered, MRI showing no intracranial mass or MS (or documentation that additional treatment is planned/initiated if present), prior adequate pharmacologic therapy (or documented recurrence after response or contraindication), planned imaging guidance, and for repeat procedures prior neurolysis must have provided significant durable relief with ≥6 months pain improvement.

"Creation of the initial lesion is considered medically necessary when ALL of the following are met:"

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