CMM-403: Neurolytic Agent Creation of Lesion

Covered: percutaneous neurolytic lesion creation (thermal radiofrequency, glycerol, or alcohol) for trigeminal neuralgia only; excluded are neurolysis for other conditions, unapproved methods, procedures without fluoroscopic/CT guidance, more than one neurolytic procedure in a 6‑month period, or more than one invasive procedure on the same date. Key requirements: documented classic unilateral shock‑like trigeminal neuralgia with consideration of alternative diagnoses, MRI showing no intracranial mass/MS (or planned/initiated treatment if present), documented trial of and inadequate response to (or contraindication to) pharmacologic therapy, planned use of fluoroscopic/CT guidance and an approved neurolytic method (and ≥6 months prior pain relief required for repeat lesions), with complete supporting documentation.

"Neurolytic creation of a lesion for trigeminal neuralgia (guideline applies only to trigeminal neuralgia and not to other conditions)."