Anthem Blue Cross Blue Shield of Georgia 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 Georgia policy (policy CG-SURG-89). It lists 6 CPT or HCPCS codes, 6 of them on the Anthem Blue Cross Blue Shield of Georgia 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 Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 61790 | On the list | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion | Policies naming 61790 |
| 61791 | On the list | Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract | Policies naming 61791 |
| 64600 | On the list | Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch | Policies naming 64600 |
| 64605 | On the list | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale | Policies naming 64605 |
| 64610 | On the list | Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring | Policies naming 64610 |
| 64999 | On the list | Unlisted procedure, nervous system | Policies naming 64999 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list