Subject:
Percutaneous Neurolysis for Trigeminal Neuralgia
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Trigeminal neuralgia (TN) is one of the most common causes of facial pain. Facial muscle spasms can be seen with severe pain giving rise to the older term for this disorder, tic douloureux.
The International Association for the Study of Pain defines trigeminal neuralgia as sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain confined to the distribution of one or more of the fifth cranial nerve's (trigeminal nerve) three branches: the ophthalmic (V1), the maxillary (V2), and the mandibular (V3) divisions.The nerve starts at the midlateral surface of the pons, and its sensory ganglion (gasserian ganglion) resides in the trigeminal fossa (Meckel's cave) in the floor of the middle cranial fossa.
The latest classification of the International Headache Society distinguishes between classic and symptomatic TN. Classic TN includes all cases without an established etiology (i.e., idiopathic, as well as those with potential vascular compression of the fifth cranial nerve). The diagnosis of classic TN also requires that there be no clinically evident neurologic deficit. The diagnosis of symptomatic TN is made when investigations identify a structural abnormality other than potential vascular compression affecting the trigeminal nerve. Such abnormalities include multiple sclerosis (MS) plaques, tumors, and abnormalities of the skull.
Treatment options for trigeminal neuralgia include pharmacologic therapy (e.g., carbamazepine, oxcabazepine) and surgical therapy (e.g., microvascular decompression, percutaneous neurolysis) for those patients refractory to pharmacologic therapy. Percutaneous neurolysis (creation of a lesion) of the gasserian ganglion or trigeminal medullary tract by stereotactic method (use of imaging guidance with fluoroscopy or CT) includes the use of thermal (radiofrequency) or chemical (glycerol or alcohol) agents.
Red flags are clinical indicators of possible serious underlying conditions requiring further medical intervention and may require urgent/emergent diagnostic imaging referral for definitive therapy. The presence of red flags in patients with pain suggests the need for further investigation and possible specialist referral as part of the overall strategy.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-403: Neurolytic Agent Creation of Lesion
| CMM-403.1: Definitions |
| CMM-403.2: General Guidelines |
| CMM-403.3: Indications |
| CMM-403.4: Non-Indications |
| CMM-403.5: Procedure (CPT®) Codes |
CMM-403.1: Definitions
Red flags indicate comorbidities that require urgent/emergent diagnostic imaging and/or referral for definitive therapy.
For the purpose of this guideline, any of the following are considered to be red flags:
® Suspected unstable fractures of the spine which may be evidenced by a history of a recent fall or injury, and major motor weakness of a limb, or progressive neurological deficits, or bladder or bowel dysfunction.
® History of cancer with suspicion of metastatic spread which may be evidenced by major motor weakness of a limb, or pain which increases at night or at rest, or progressive neurological deficits, or bladder or bowel dysfunction, or unexplained weight loss of more than 10 pounds in 6 weeks.
® Infection with suspicion of an epidural abscess/discitis which may be evidenced by progressive neurological deficits, or fever of 100.4 for more than 48 hours, and C- reactive protein >10 mg/L, or recent (within 2 weeks) interventional spine procedures, or ESR >20 mm/hr, or immunocompromised (either immunodeficiency from any cause or IV drug abuse).
® Cauda equina syndrome which may be evidenced by bladder or bowel dysfunction, or saddle anesthesia, or progressive neurological deficits.
CMM-403.2: General Guidelines
The presence of a red flag condition does not preclude the certification for creation of lesion by neurolytic agent. Medical necessity must be met despite the presence of any red flag condition.
CMM-403.3: Indications
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-like pain in the forehead, and/or face, and/or jaw
® There is a diagnosis of trigeminal neuralgia with evidence of consideration of alternative diagnoses
† Imaging which includes either of the following:
® MRI demonstrates absence of an intra-cranial mass or multiple sclerosis
® If multiple sclerosis, intracranial mass or other potentially causative condition is present, treatment in addition to percutaneous therapy has been planned or initiated
† Prior therapy which includes any of the following:
® Neuropathic pain pharmacologic therapy with adequate dosing has been tried without adequate response
® There is a recurrence of signs and symptoms after a period of response to Rx therapy
® There are contraindications to available pharmacologic therapies
† Planned treatment includes both of the following:
® Imaging guidance with fluoroscopy or CT
® Neurolytic method is thermal radiofrequency, glycerol, or alcohol
Creation of the second or subsequent lesion is considered medically necessary when all of the following are met:
† History, signs, and symptoms include all of the following:
® Recurrent, severe, unilateral, shock-like pain in the forehead, and/or face, and/or jaw
® There is a diagnosis of trigeminal neuralgia with evidence of consideration of alternative diagnoses
® Previous neurolysis produced significant and durable pain relief
® MRI at time of initial treatment demonstrated absence of an intra-cranial mass or multiple sclerosis
® If multiple sclerosis, intracranial mass or other potentially causative condition is present, treatment in addition to percutaneous therapy has been prescribed
† Prior therapy includes both of the following:
® There is a response of at least 6 months pain improvement after previous neurolysis
® Neuropathic pain pharmacologic therapy with adequate dosing has been tried since recurrence of symptoms without adequate response or there are contraindications to available pharmacologic therapies
† Planned treatment includes both of the following:
® Imaging guidance with fluoroscopy or CT
® Neurolytic method is thermal radiofrequency, glycerol, or alcohol
CMM-403.4: Non-Indications
Creation of lesion by neurolytic agent is not considered medically necessary when performed without fluoroscopic or CT imaging guidance.
CMM-403.5: Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor. |
| CPT® | Code Description/Definition |
61790 | Creation of Lesion by Stereotactic* Method, Percutaneous, by Neurolytic Agent (e.g., Alcohol, Thermal, Electrical, Radiofrequency); Gasserian Ganglion |
61791 | Creation of Lesion by Stereotactic* Method, Percutaneous, by Neurolytic Agent (e.g., Alcohol, Thermal, Electrical, Radiofrequency); Trigeminal Medullary Tract |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. |
Medicare Coverage:
There is no National Coverage Determination (NCD) for Percutaneous Neurolysis for Trigeminal Neuralgia. National Coverage Determination (NCD) for Induced Lesions of Nerve Tracts (160.1) notes that payment may be made for these denervation procedures when used in selected cases (concurred in by the Medicare Administrative Contractor’s medical staff) to treat chronic pain. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
National Coverage Determination (NCD) for Induced Lesions of Nerve Tracts (160.1). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Percutaneous Neurolysis for Trigeminal Neuralgia
Neurolysis for Trigeminal Neuralgia
Trigeminal Neuralgia
Tic Douloureux
References:
1. Gronseth G., Cruccu, G., Alksne, J., et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. Oct 7 2008;71(15):1183-1190.
2. Singla A. Trigeminal Neuralgia Chapter 90. Frontera: Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, PA Saunders Elsevier 2008.
3. Trigeminal Neuralgia Fact Sheet https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Trigeminal-Neuralgia-Fact-Sheet. Accessed August 15, 2018.
4. Harries A. M., Mitchell, R. D. Percutaneous glycerol rhizotomy for trigeminal neuralgia: safety and efficacy of repeat procedures. Br J Neurosurg. Apr 2011;25(2):268-272.
5. Erdine S., Ozyalcin, N. S., Cimen, A., et al. Comparison of pulsed radiofrequency with conventional radiofrequency in the treatment of idiopathic trigeminal neuralgia. Eur J Pain. Apr 2007;11(3):309-313.
6. Singla A. Trigeminal Neuralgia 2nd ed. Philadelphia, PA Saunders Elsevier 2008.
7. Bennetto L., Patel, N. K., Fuller, G. Trigeminal neuralgia and its management. BMJ. Jan 27 2007;334(7586):201-205.
8. Bogduk N. Pulsed radiofrequency. Pain Med. Sep-Oct 2006;7(5):396-407.
9. Kanpolat Y., Savas, A., Bekar, A., et al. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery. Mar 2001;48(3):524-532; discussion 532-524.
10. Lopez B. C., Hamlyn, P. J., Zakrzewska, J. M. Systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia. Neurosurgery. Apr 2004;54(4):973-982; discussion 982-973.
11. Cheshire W. P. Trigeminal neuralgia: diagnosis and treatment. Curr Neurol Neurosci Rep. Mar 2005;5(2):79-85.
12. Cheshire W. P. Trigeminal Neuralgia. Mayo Clinic. February 2007 2007;11(1):69-74.
13. Zakrzewska J. M. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain. Jan-Feb 2002;18(1):14-21.
14. Hojaili B., Barland, P. Trigeminal neuralgia as the first manifestation of mixed connective tissue disorder. J Clin Rheumatol. Jun 2006;12(3):145-147.
15. Cohen A. S., Matharu, M. S., Goadsby, P. J. Trigeminal autonomic cephalalgias: current and future treatments. Headache. Jun 2007;47(6):969-980.
16. DaSilva A. F., Goadsby, P. J., Borsook, D. Cluster headache: a review of neuroimaging findings. Curr Pain Headache Rep. Apr 2007;11(2):131-136.
17. Chole R., Patil, R., Degwekar, S. S., et al. Drug treatment of trigeminal neuralgia: a systematic review of the literature. J Oral Maxillofac Surg. Jan 2007;65(1):40-45.
18. Jorns T. P., Zakrzewska, J. M. Evidence-based approach to the medical management of trigeminal neuralgia. Br J Neurosurg. Jun 2007;21(3):253-261.
19. Rasche D., Kress, B., Schwark, C., et al. Treatment of trigeminal neuralgia associated with multiple sclerosis: case report. Neurology. Nov 9 2004;63(9):1714-1715.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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