Anthem Blue Cross Connecticut Commercial Clinical Policy

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

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.