Anthem Blue Cross Blue Shield of California policy
CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-89). It lists 6 CPT or HCPCS codes, 6 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- CG-SURG-89
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 61790 | On the list | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion [specified as RF] | Policies naming 61790 |
| 61791 | On the list | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract [specified as RF] | Policies naming 61791 |
| 64600 | On the list | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch [specified as RF] | Policies naming 64600 |
| 64605 | On the list | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale [specified as RF] | Policies naming 64605 |
| 64610 | On the list | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring [specified as RF] | Policies naming 64610 |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list