CMM-403: Neurolytic Agent Creation of Lesion

Percutaneous creation of a neurolytic lesion for trigeminal neuralgia using thermal radiofrequency, glycerol, or alcohol is covered when performed with fluoroscopic or CT guidance and is not medically necessary if done without fluoroscopic/CT guidance. Coverage requires documented recurrent, severe unilateral shock‑like facial/jaw pain with a trigeminal neuralgia diagnosis (alternatives considered), MRI showing no intracranial mass or MS (or documentation that additional treatment is planned if MS/mass present), prior adequate neuropathic pharmacotherapy or contraindication, and for repeat lesions prior neurolysis must have given significant durable relief with ≥6 months benefit.

"Creation of the initial lesion is considered medically necessary when all of the following are met: History, signs, and symptoms include both of the following: Recurrent, severe, unilateral, shock-..."