Three Automations Providers and DMEs can build with ChatGPT and Claude today
Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia Form


Radiofrequency Neurolysis for Trigeminal Neuralgia

Indications

(681050) Has the patient not responded to or cannot tolerate medical management for trigeminal neuralgia? 
(681051) Has the patient not responded to or cannot tolerate invasive surgery for trigeminal neuralgia? 
(681052) Has the patient not responded to or cannot tolerate other percutaneous treatments for trigeminal neuralgia? 

Contraindications

(681053) Does the patient meet all the above criteria (medical management, invasive surgery, and other percutaneous treatments) for trigeminal neuralgia? 

Pulsed Radiofrequency Therapy for Trigeminal Neuralgia

Notes: Pulsed Radiofrequency Therapy is considered not medically necessary for trigeminal neuralgia.

Indications

(681054) Is Pulsed Radiofrequency therapy being considered for treatment of trigeminal neuralgia? 

Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the use of radiofrequency (RF) neurolysis and pulsed radiofrequency (PRF) therapy for the treatment of trigeminal neuralgia.

Note: Please see the following related document for additional information:

  • SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Clinical Indications

Medically Necessary:

Radiofrequency (RF) neurolysis is considered medically necessary for those with trigeminal neuralgia who do not respond to or cannot tolerate medical management, invasive surgery, or other percutaneous treatments.

Not Medically Necessary:

Radiofrequency (RF) neurolysis is considered not medically necessary for those with trigeminal neuralgia who do not meet the above criteria.

Pulsed radiofrequency (PRF) therapy as a treatment for trigeminal neuralgia is considered not medically necessary.