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National Medical Policy


Trigeminal Neuralgia, Interventional

Policy Number: NMP73
Effective Date*: October 2003

February 2014

This National Medical Policy is subject to the terms in the
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Reference/Website Link

Stereotactic Radiosurgery; Stereotactic
Radiation Therapy: Stereotactic Radiosurgery
(SRS) and Stereotactic Body Radiation Therapy
Cranial Stereotactic Radiosurgery (SRS) and
Cranial Stereotactic Radiotherapy:

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Trigeminal Neuralgia, Interventional Treatments Feb 14


Inc. clonazepam (Klonopin). considers pulsed radiofrequency for the treatment of trigeminal neuralgia not medically necessary due to lack of evidence in the peer review literature demonstrating its safety and efficacy for this indication. follow the Health Net Hierarchy of Medical Resources for guidance. This list of codes may not be all inclusive. an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. and 2.2)   If more than one source is checked. have led to intolerable side effects or have failed (e. carbamazepine (Tegretol). Interventional Treatments Feb 14 2 .. 3. but not by placebo injection.g. 5. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90. and baclofen). National Coverage Manual or region specific LCD/Article. Percutaneous glycerol rhizotomy (or injections) Percutaneous radiofrequency rhizolysis/rhizotomy/ cryoanalgesia Balloon microcompression Microvascular decompression Stereotactic Radiosurgery (Gamma Knife Radiosurgery) Criteria: 1. 4. considers all of the following surgical procedures medically necessary for the treatment of trigeminal neuralgia (also known as tic douloureux) when all of the criteria below are met: 1. Current Policy Statement Health Net Inc. you need to access all sources as. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. phenytoin. There is documentation that the pain can be abolished by local anesthetic injection. Coverage is determined by the benefit documents and medical necessity criteria.determinations for your region. 2. Not Medically Necessary Health Net. Patient has pain characteristic of trigeminal neuralgia for > 6 months. Trigeminal Neuralgia. Pharmacotherapies that often provide significant benefit are contraindicated. on occasion. 3. Definitions TN MVD GKS CRF PRF RF-TR BTN ITN Trigeminal neuralgia Microvascular decompression Gamma knife surgery Continuous radiofrequency Pulsed radiofrequency Radiofrequency trigeminal rhizotomy Bilateral trigeminal neuralgia Idiopathic trigeminal neuralgia Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. If there is no NCD.

complex (List separately in addition to code for primary procedure) Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) Stereotactic radiosurgery (particle beam. other peripheral nerve or branch Unlisted procedure. were observed and the Trigeminal Neuralgia.22 Trigeminal neuralgia Postherpetic trigeminal neuralgia CPT Codes 61793 61796 61797 61798 61799 61800 63620 63621 64400 64640 64999 Stereotactic radiosurgery (particle beam. lateral approach. one or more sessions (CPT code deleted in 2011. trigeminal nerve. 648 patients with idiopathic trigeminal neuralgia. 2014. each additional cranial lesion. gamma ray or linear accelerator).1 350. 63620-63621) Stereotactic radiosurgery (particle beam.0 B02. skill of radiofrequency thermocoagulation and complications. each additional spinal lesion (List separately in addition to code for primary procedure) Injection.8 053. anterior approach and other approach from July 2001 to March 2011 in one hospital. gamma ray or linear accelerator). 1 spinal lesion Stereotactic radiosurgery (particle beam. Interventional Treatments Feb 14 3 . simple (List separately in addition to code for primary procedure) Stereotactic radiosurgery (particle beam. gamma ray or linear accelerator). and discussed the method. ICD-9 Codes 350. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. gamma ray or linear accelerator). 2014 implementation date. 1 complex cranial lesion Stereotactic radiosurgery (particle beam. anesthetic agent. each additional cranial lesion. gamma ray or linear accelerator). who were treated by radiofrequency thermocoagulation via foramen infraorbitale approach. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1. 1 simple cranial lesion Stereotactic radiosurgery (particle beam.12 Trigeminal neuralgia Other specified trigeminal neuralgia disorders Postherpetic trigeminal neuralgia ICD-10 Codes G50.On October 1. the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. gamma ray or linear accelerator). To report. see 61796-61800. any division or branch Destruction by neurolytic agent. gamma ray or linear accelerator). nervous system (No specific code for pulsed radiofrequency neurolysis HCPCS Codes N/A Scientific Rationale – Update February 2013 Liu et al (2012) analyzed the clinical efficacy of radiofrequency thermocoagulation in the treatment of idiopathic trigeminal neuralgia.

3% via foramen infraorbitale approach.053. and reduce complications.24%. respectively. and the QOL in all three groups had increased significantly compared to baseline. CT location can improve the accuracy of puncture. Patients were assessed for pain intensity.48%.01).33%.0% via lateral approach and 95. Investigators concluded patients who receive PRF combined with CRF to the GG can achieve comparable pain relief to those who receive CRF alone. 12 months and at end times were 90. and intensity of facial dysesthesia before (baseline). 395 patients were followed up from 6 months to 2 years. Sixty-one TN patients treated using MVD and eighty-six TN patients treated using GKS were enrolled by means of telephone. The efficacy in pain relief was most significant on the seventh day after treatment and there were no significant differences between groups. Investigators concluded immediate pain relief with MVD treatment is higher than with GKS. but pain relief rates in the long-term showed no significant differences (P>0. and shorter exposure of CRF could result in less destruction of the target tissue. Bozkurt et al (2012) evaluated the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). The operation is simple. for forty-two MVD-treated patients. the patients had originally presented from December 1996 to June 2010. or 42°C PRF for 10 minutes (min) followed by 75°C CRF for 120 s to 180 s (PCRF group). safety and complications. and at the final follow-up.67% and 90% for sixty GKS-treated patients. Good response was achieved after retreatment with radiofrequency thermocoagulation in recurrent patients. and the complication is fewer. 6 months and 12 months. >70% of patients in each group had complete pain relief. three months. Investigators concluded the clinical efficacy of radiofrequency thermocoagulation in the treatment of idiopathic trigeminal neuralgia is good and reliable.5% within two years.0%. and 95. 20. Pain relief rates in the short-term (first month) demonstrated statistically significant differences (P<0.33%. P=0. One hundred and two patients were followed for 3-151 months. Cumulative pain relief rates at 1. six months. the rate of pain control was 98. The recurrent rate within one year was 9. quality of life (QOL). and at seven days.5% via former approach. The effects of two methods for treatment of TN was not statistically different (χ(2) = 2. 6. 86. 91. letter or out-patient recheck. and 12 months after the procedure. Patients were analyzed after RF-TR in terms of outcome. Eighty-nine BTN patients underwent 186 RF-TR procedures. but most persistent in the LCRF group. After 12 months. The intensity of facial dysesthesia was mildest in the SCRF group and most severe in the PCRF group on the seventh day after the procedure.05). 95. the indication is wide. but in the long term both treatments were comparable. Sixty patients diagnosed with classic trigeminal neuralgia (TN) were treated with either 75°C CRF for 120 s to 180 s (SCRF group). 75°C CRF for 240 s to 300 s (LCRF group). 83. Tang et al (2012) evaluated the curative effects and complications when using microvascular decompression (MVD) or gamma knife surgery (GKS) to treat trigeminal neuralgia (TN) and investigated the prognosis for TN after these treatments. and 23.86%. respectively. The overall response rate was 96.6%. 92. Interventional Treatments Feb 14 4 . Li et al (2012) conducted a prospective randomized controlled study to evaluate whether continuous radiofrequency (CRF) combined with pulsed radiofrequency (PRF) to the Gasserian ganglion (GG) decreases the side effects of CRF while preserving efficacy. Eightyseven patients had idiopathic trigeminal neuralgia (ITN) and two patients had Trigeminal Neuralgia.24%. A chi-square test was applied to follow-up data on pain relief after 1 month. After the first treatment of the 648 patients.152).clinical efficacy was evaluated.

and effortlessly repeatable procedure for treating BTN. Synchronized pain was observed in 25 (28. 229 patients in five studies had percutaneous interventions applied to the Gasserian ganglion.1%). Two isocentres increased the incidence of sensory loss. Early (<6 months) pain recurrence was observed in 11 (12. No studies addressing microvascular decompression (which is the only non-ablative procedure) met the inclusion criteria. Three studies had sufficient outcome data for analysis.9%) were women and 33 (37.multiple sclerosis (2. of 87 participants.71 ± 77. They searched randomised controlled trials and quasirandomised controlled trials of neurosurgical interventions used in the treatment of classical trigeminal neuralgia. in terms of low morbidity and mortality rates and high rate of satisfactory pain relief. investigators compared radiation treatment to the trigeminal nerve at one or two isocentres in the posterior fossa. allowing patient cooperation for controlled and selective lesioning. It was not possible to undertake meta-analysis because of differences in the intervention modalities and variable outcome measures. Anesthesia was administered at a determined optimal level. keratitis in two (1. Ages ranged from 29 to 85 years.13 months. compared two techniques of radiofrequency thermocoagulation (RFT) of the Gasserian ganglion at six months.72.0%) patients.1%) were men. One trial.2%) patients. Investigators concluded RF-TR is an effective.46 to 1. Scientific Rationale – Update February 2011 A 2011 Cochrane review (Zakrzewska and Akram) assessed the efficacy of neurosurgical interventions for classical trigeminal neuralgia in terms of pain relief. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Sensory changes were common in the continuous treatment group.1%). well-controlled. Familial occurrence was seen in two (2.70.1%).5%). Acute pain relief was reported in 86 (96. selective. 36 patients required the second procedure and 7 required the third procedure.04) but relief was more sustained and side effects fewer if a neuronavigation system was used. Two authors independently assessed trial quality and extracted data. Trigeminal Neuralgia. Eleven studies involving 496 participants met some of the inclusion criteria stated in the protocol. There were insufficient data to determine if one technique was superior to another. and 87 patients in one study underwent two modalities of stereotactic radiosurgery (Gamma Knife) treatment. especially in the elderly. Fifty-six (62. 95% confidence intervaI (CI) 0.3%) and late (>6 months) recurrence in 25 (28. Both techniques produced pain relief (not significantly in favour of neuronavigation (RR 0.2%) patients.2%). The mean follow-up period was 101.30 to 1. 95% CI 0.6%) patients.71).7 ± 87.7 months. Interventional Treatments Feb 14 5 . Relapses were nonsignificantly reduced with two isocentres (risk ratio (RR) 0. Pain occurrence on the contralateral side was observed with an average duration of 124. The remaining eight studies did not report outcomes as predetermined in our protocol. One hundred and eighty patients in five studies had peripheral interventions.1%) patients. Complications included diminished corneal reflex in four (2. Increased age and prior surgery were predictors for poorer pain relief. masseter dysfunction in four (2. When this group were converted to conventional (continuous) treatment these participants achieved pain control comparable to the group that had received conventional treatment from the outset. A third study compared two techniques for RFT in 54 participants for 10 to 54 months. During follow-up. In another trial. quality of life and any harms. Pulsed RFT resulted in return of pain in all participants by three months. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. dysesthesia in two (1. All but two of the identified studies had a high to medium risk of bias because of either missing data or methodological inconsistency. and anesthesia dolorosa in one (0. which involved 40 participants.

“stunning” the nerve rather than destroying nerve tissue. The available peer review literature regarding the use of pulsed radiofrequency for the treatment of trigeminal neuralgia is limited. the use of PRF cannot be similarly advocated in view of the methodological quality of the included study.g. glycerol injection. Large prospective. clinical advantages and mechanisms of this treatment remain unclear. One small. ataxia. one against sham intervention. which entails posterior fossa craniotomy and has a Trigeminal Neuralgia. neurosurgical options include microvascular decompression. conventional radiofrequency was performed on the group initially treated with pulsed radiofrequency because all patients in this group still had intractable pain.Chua et al (2011) evaluated the efficacy of Pulsed Radiofrequency (PRF) treatment in chronic pain management in randomized clinical trials (RCTs) and well-designed observational studies. with the anti-epileptic drug carbamazepine (Tegretol) being the drug of choice in a substantial number of cases. one in lumbosacral radicular pain. The former approaches include radiofrequency rhizolysis. Studies have shown that cryoanalgesia provides temporary pain relief or cure with minimal morbidity (e. Interventional Treatments Feb 14 6 . one in cervical radicular pain. randomized studies with long term-follow up are necessary to validate the clinical value of this approach. Scientific Rationale Trigeminal neuralgia (TN). The principal open approach is microvascular decompression. The use of PRF in lumbar facet arthropathy and trigeminal neuralgia was found to be less effective than conventional RF thermocoagulation techniques. confusion. Upon failure of further attempts at pharmaceutical control. prospective randomized study (Erdine et al) compared the effect of pulsed radiofrequency (PRF) to conventional radiofrequency (CRF) in the treatment of idiopathic trigeminal neuralgia. no permanent sensory loss) in patients with refractory TN. one in trigeminal neuralgia. and rhizotomy. drowsiness. The investigator reported. drug treatment is either ineffective or the adverse effects become intolerable (poor liver function. also known as tic douloureux. the use of PRF to the dorsal root ganglion in cervical radicular pain is compelling. Although trigeminal neuralgia is initially treated medically. balloon microcompression techniques and cryoanalgesia. Scientific Rationale – Update April 2008 Pulsed radiofrequency has been investigated in patients with neuropathic pain syndromes that have been poorly controlled with other oral and invasive treatments. one against corticosteroid injection. The reviewers noted that from the available evidence. Two trials were conducted in patients with lower back pain due to lumbar zygapophyseal joint pain. and allergic responses). and another in chronic shoulder pain. Six RCTs that evaluated the efficacy of PRF. Surgical treatment can be divided into percutaneous and open interventions. and the rest against conventional RF thermocoagulation. at the end of 3 months. Pulsed radiofrequency applies short bursts of radiofrequency energy to the target nerve at a lower temperature.. PRF application to the supracapular nerve was found to be as efficacious as intra-articular corticosteroid in patients with chronic shoulder pain. At the present time. is a disorder of the fifth cranial (trigeminal) nerve that causes episodes of intense. With regards to its lumbosacral counterpart. stabbing pain in the face. This led the investigator to conclude that pulsed radiofrequency is not an effective method of pain treatment for idiopathic trigeminal neuralgia. short-term. balloon compression.

Even the elderly or medically infirm can undergo this treatment. Alksne J. Added Medicare Table with links to LCDs and article. Codes updated. Onset of pain relief may occur one day to four months after the procedure. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review). Zakrzewska JM. Burchiel K. Update – no revisions Update – no revisions. the target area is the trigeminal nerve. In general. Major complications have not been reported. Nurmikko T. Code updates This policy is based on the following evidence-based guidelines: 1. Argoff C. while the open approach is recommended for younger and healthier subjects. Report of the Quality Trigeminal Neuralgia. The patient's age or medical condition does not affect the decision to have SRS. elderly or medically debilitated patients. Review History October 2003 April 2006 April 2008 April 2011 February 2012 February 2013 February 2014 Medical Advisory Council Update – no revisions Added pulsed radiofrequency for treatment of trigeminal neuralgia as investigational and therefore not medically necessary. Update. Patients who are receiving anticoagulants for other medical conditions do not have to stop or reverse the anticoagulation therapy prior to SRS. The treatment does not require general anesthesia. No revisions. patients with multiple sclerosis.small incidence of serious neurological morbidity. Additional numbness in the face or new facial sensations occur in less than 10 percent of patients. Patients who are concerned about the possibility of numbness are particularly good candidates for SRS. Two hundred-one beams of cobalt-60 radiation are focused precisely on a specific region in the brain. because the chance of postoperative numbness occurring is very small. Gamma Knife radiosurgery can be repeated. Stereotactic Radiosurgery (SRS). just where it leaves the brain. but not until at least four months after the original procedure. In the case of TN. Cruccu G. Those who have had previous procedures for TN may also undergo SRS. Excellent or good pain relief occurs in approximately 85 to 90 percent of patients. and the patient stays in the hospital for less than five hours. There are theoretical possibilities of delayed complications such as brain damage or brain tumor formation. Any patient with trigeminal neuralgia who has pain or has difficulty with the medicines used to relieve the pain is an excellent candidate for SRS. or individuals who have failed to attain pain relief from the open approach are encouraged to use the percutaneous approaches. About half of patients will experience pain relief within four weeks. Brainin M. has been investigated as an alternative to these neurosurgical treatments without making an incision. but these are rare and have not been reported to occur in any patients treated for trigeminal neuralgia. Patients who poorly tolerate medicines given for sedation and relief of pain during a procedure are also very suitable for SRS because these medications are not necessary. Gronseth G. Recurrent pain occurs within three years in 10 percent of patients. also referred to as Gamma Knife Radiosurgery. Interventional Treatments Feb 14 7 . Code updates Update – no revisions.

2012 May. J Clin Neurosci. 8. 2. Microvascular decompression for trigeminal neuralgia: update. World Neurosurg. Harrisburg (PA): IRSA. Cyberknife radiosurgery in treating trigeminal neuralgia. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management.2012:328936.37(6):616-20. Zakrzewska JM. 14. et al. Gerodontology. Available at: http://www. Trigeminal neuralgia: diagnostic criteria. et al. 2012 Dec. 9. J Neurosurg. 3.2. . Interventional Treatments Feb 14 8 . Hou Y. Fraioli C. Tang X. Zhong Q. Liu Y.19(10):1401-3.19(6):824-8.irsa. Treatment of primary trigeminal neuralgia with radiofrequency thermocoagulation: report of 648 consecutive cases. February 2013. Carron R. Mao B.117 Suppl:181-8.Microvascular decompression for trigeminal neuralgia in patients with and without prior stereotactic radiosurgery. 11 p. Trigeminal Neuralgia. Neurology 2008 Oct 7. 2012 Oct 3. 2009 Jan. 7. Ozdemir M. J Neurointerv Surg.5(1):81-5. Efficacy and prognosis of trigeminal neuralgia treated with surgical excision or gamma knife surgery. Lee JK. Fraioli MF. 4. 2012 Jun. IRSA. Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Wang Y. Bordia R. using a dedicated linear accelerator. Shu Z. Patterns of pain-free response in 497 cases of classic trigeminal neuralgia treated with Gamma Knife surgery and followed up for least 1 year.21(4):466-9 Luo F. Bajwa ZH. Curr Opin Neurol. Ho CC. 12. et al.pdf References – Update February 2014 1. J Korean Neurosurg Soc. 6. J Clin Neurosci. 2013 Jan 16. Ko HC. Percutaneous trigeminal ganglion balloon compression rhizotomy: experience in 27 patients. Yuan CY. Lazzara BM.78(12):149-54. Wang W. Management of bilateral trigeminal neuralgia with trigeminal radiofrequency rhizotomy: a treatment strategy for the life-long disease. 2012 May. Meng L.Long term outcomes of gamma knife radiosurgery for typical trigeminal neuralgia-minimum 5-year follow-up. Pulsed radiofrequency treatment for idiopathic trigeminal neuralgia: A retrospective analysis of the causes for ineffective pain relief. Ni J. Acta Neurochir (Wien). Preliminary results of 45 patients with trigeminal neuralgia treated with radiosurgery compared to hypofractionated stereotactic radiotherapy. et al. A retrospective study. 11. . Zhong Nan Da Xue Xue Bao Yi Xue Ban.51(5):276-80 Li X. Clinical outcomes of 114 patients who underwent γ-knife radiosurgery for medically refractory idiopathic trigeminal neuralgia. Shanghai Kou Qiang Yi Xue. 13. Zhou ZG. A prospective study of Gasserian ganglion pulsed radiofrequency combined with continuous radiofrequency for the treatment of trigeminal neuralgia. 5.154(5):785-91. 2012 Aug. Strigari L. Ibrahim S. et al. clinical aspects and treatment outcomes. 10. Yang L. et al. 2012 Oct. 2012 Jun.71(15):1183-90.19(1):71-4. Chen JC. References – Update February 2013 1. Coakham HB. Al-Beyati ES. Tuleasca C. Khan Ŝmigoc T. Eur J Pain. 2013 Jan 1. 2012 Jun. Trojnik T. Trigeminal neuralgia. Wang T. et al. Liu C. 2012. Resseguier N.25(3):296-301. 2012 Jan. Li P. Bozkurt M. 2012 Jul. ScientificWorldJournal. Ortiz O. J Clin Neurosci. Choi HJ. UpToDate.

Sheehan JP. Chen JC. et al. 2008 Apr. Yen CP. Comparison of percutaneous balloon compression and glycerol rhizotomy for the treatment of trigeminal neuralgia. et al. 4. Chen JF. Lee ST. J Craniofac Surg.153(4):763-71. Gamma Knife radiosurgery for trigeminal neuralgia. Microvascular decompression treatment for trigeminal neuralgia. et al. 2009. 4. De Santis M. outcomes. Lozano A. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications-a review. Park KJ. Neurosurgical interventions for the treatment of classical trigeminal neuralgia. Schlesinger D. 5. 7. Li P. Repeat Gamma Knife Radiosurgery for Trigeminal Neuralgia. Trigeminal Neuralgia. J Neurosurg. Berkowitz O. Campos WK. Fontaine D. Gamma knife radiosurgery in patients with trigeminal neuralgia: Quality of life. Mao B. 2011 May. 8. Nonisocentric radiosurgical rhizotomy for trigeminal neuralgia. Arq Neuropsiquiatr. Adler JR Jr.References – Update February 2012 1.69(2A):221-6 3. Acta Neurochir (Wien). Neurosurgery. Sluijter ME. References – Update April 2008 1. 2009. 2010 Feb 26. Fletcher LH. 2011 Apr. 2009. Harries AM. Ghanta R. [Epub ahead of print] Azar M.64(2 Suppl):A96-A101. Percutaneous glycerol rhizotomy for trigeminal neuralgia: safety and efficacy of repeat procedures. Clinical outcomes of 114 patients who underwent Gamma-knife radiosurgery for medically refractory idiopathic trigeminal neuralgia. 2011 Sep 7. et al. Mitchell RD. World Neurosurg. and complications. et al. Schechtmann G. Pradilla G. 2011 Nov 3 2. Kouzounias K. 2011 Nov. Repeated Percutaneous Balloon Compression for Recurrent Trigeminal Neuralgia: A Long-Term Study. Chua NH. 2. Liu Y. Cochrane Database Syst Rev. Expert Rev Med Devices. Sekula RF. Clin Neurol Neurosurg. Efficacy and safety of motor cortex stimulation for chronic neuropathic pain: Critical review of the literature. 2011 Apr.111(2):174-178. Tu PH. Kondziolka D.110(2):251-256.22(3):894-8. Wang W. Fariselli L. Zhong Q. Gupta G. Neurosurgery. Yahyavi ST. 2011 Nov 7 6. Effectiveness of Repeat Glycerol Rhizotomy in Treating Recurrent Trigeminal Neuralgia. Batra S. Br J Neurosurg. 5.64(2 Suppl):A84-A90. Vissers KC. Microvascular Decompression for Trigeminal Neuralgia in Patients with and without Prior Stereotactic Radiosurgery: A Retrospective Review of a Consecutive Single-Surgeon Experience. J Neurosurg.19(1):71-4 9. 3.8(6):709-21 11. Chakravarthi PS. 2011 Aug 1 10. Bender M.108(4):689-91. Marchan EM. Lind G. 2011 Apr. Bower R. J Neurosurg. 2011 Nov 1. Akram H. Marras C. 2012 Jan. CyberKnife radiosurgery as a first treatment for idiopathic trigeminal neuralgia. World Neurosurg. Neurosurgery. 2009. et al. et al. Zakrzewska JM. Linhares MN.25(2):268-72. Kattimani V. Bitaraf MA. A prospective study of 39 patients with trigeminal neuralgia treated with percutaneous balloon compression. Interventional Treatments Feb 14 9 . Microvascular decompression for trigeminal neuralgia in elderly patients.9:CD007312. Hamani C. References – Update April 2011 1. J Clin Neurosci. Neurosurgery.

2007. Technique and results in 191 patients. Neurosurg Focus. Eide PK.80(1-2):437-9. No Shinkei Geka. J Neurosurg. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med. 9. Eur J Pain. Missouri Med. Guo S.7(11):1565-79. and results in 200 patients treated at the Midwest gamma knife center.11(3):309-13. 6.6(1):46-50. 2001. Pollock BE. Cimen A. techniques. Kondziolka D. Interventional Treatments Feb 14 10 . J Neurosurg. without general impairment of sensory perception. Microvascular decompression for trigeminal neuralgia in older patients. Sindou M. Mayo Clin Proc. Ozyalcin NS. 11. Kondziolka D. Das B. 1999 Mar. Neurosurg Clin North Am. 1997. 8. 1997. Trigeminal neuralgia: for one nerve a multitude of treatments. Pain. Lee GP.107(6):1144-53. Expert Rev Neurother. et al. Cheshire WP. Mendoza N. Chilton JD. Comparison of pulsed radiofrequency with conventional radiofrequency in the treatment of idiopathic trigeminal neuralgia. Macrea L. References Initial 1. 2007 Apr.17(4):367-372. The Mayo Clinic gamma knife experience: Indications and initial results. Br J Neurosurg. Neurosurg. Leston J. 1999. Surgical treatment of trigeminal neuralgia.18(1):42-47. Onoda K. 10. 10. Stubhaug A. 7. Date I. 3. 4.23(6):E8 5. 7. Illingworth RD.94(7):346-353. Erdine S. Rand RW. 1995. J Indian Med Assoc. 5. 2002.9:13-19. Trigeminal Neuralgia. et al. Leksell gamma knife treatment of tic douloureux. Trigeminal neuralgia treated by microvascular decompression: A long-term follow-up study. Flickinger JC.8(1):79-85. Relief of trigeminal neuralgia after percutaneous retrogasserian glycerol rhizolysis is dependent on normalization of abnormal temporal summation of pain. Pain Pract. The longer term effect of pulsed radiofrequency for neuropathic pain. Brisman R. 2006 Mar. Gamma knife radiosurgery for trigeminal neuralgia. 4. 2006 Sep-Oct. Chao ST. 1996. 2007 Nov. Van Zundert J. Review of the Treatment of Trigeminal Neuralgia with Gamma Knife Radiosurgery. Munglani R. Barker FG. 1995. Racz GB.8(1):75-78. et al. Semin Neurol.334:1077-1083. et al. Radiofrequency procedures.74:5-13. Cappabianca P. Pain Med. 1998. et al. Decullier E. 2008 Mar 12. 8. 1997.39(1):37-45. 2008 Jan. Cahana A. et al.99(12):704-709. et al. Reuther AM. Gamma knife radiosurgery: Indications. Percutaneous retrogasserian glycerol rhizolysis for treatment of trigeminal neuralgia. Saha SP. 9. 6. Lunsford LD. Gamma Knife stereotactic radiosurgical treatment of idiopathic trigeminal neuralgia: long-term outcome and complications.7(5):411-23. 2. Ruiz-Lopez R. Smith JR. 2007 Dec. Stereotact Funct Neurosurg. 1997. Trigeminal neuralgia: Current concepts and management.36(1):45-9. Neurosurg Clin North Am. Stereotactic radiosurgery for the treatment of trigeminal neuralgia. Pulsed radiofrequency: current clinical and biological literature available.2. Clin J Pain. Microvascular decompression for primary trigeminal neuralgia: long-term effectiveness and prognostic factors in a series of 362 consecutive patients with clear-cut neurovascular conflicts who underwent pure decompression. et al. et al. Agari T. Fountas KN. 3.86(3):135-146.43(30):462-472.

regulatory status of the drug or device. Important Notice General Purpose. J Neurosurg. A twenty-year experience. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure.A comparison of their efficacy in the treatment of trigeminal neuralgia. all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. No Medical Advice. 1995. Members should consult with their treating physician in connection with diagnosis and treatment decisions. For information regarding the definitions of terms used in the Policies. et al. drug.48(3):608-614. Tan LK. drug. The conclusion that a procedure. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature.90(5):828-832. service or supply is covered. service or supply. limitations. contact your provider representative. All terms are defined by Health Net. new or revised policies require prior notice or website posting before an amendment is deemed effective. excluded. 13. Health Net reserves the right to amend the Policies without notice to providers or Members.9(2):165169. drug. terms and conditions of the Trigeminal Neuralgia. limited. The determination of coverage for a particular procedure. The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures. Neurology. The Policy is effective as of the date determined by Health Net. The policy provides for clearly written. Interventional Treatments Feb 14 11 . The date of posting is not the effective date of the Policy. Medical policy is not intended to override the policy that defines the member’s benefits. service or supply is medically necessary does not constitute coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure. 1993. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. and evidence-based guidelines and positions of select national health professional organizations. and exclusions of the member's contract. 15. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements. drug. 1999. service or supply is not based upon the Policies. service or supply is medically necessary. 14. In all cases.12. The Policies do not constitute medical advice. Glycerol versus radiofrequency rhizotomy -. Policy Effective Date and Defined Terms. The Policies do not include definitions. * In some states. Policy Limitation: Member’s Contract Controls Coverage Determinations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms. new or revised policies require prior notice or posting on the website before a policy is deemed effective. In order to be eligible. In some states. Acta Neurochir. No Authorization or Guarantee of Coverage. reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). For information regarding the effective dates of Policies. limitations. nor is it intended to dictate to providers how to practice medicine. but rather is subject to the facts of the individual clinical case. and dollar caps apply to a particular procedure. Br J Neurosurg. final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language. et al. evidence-based guidelines of governmental bodies. the requirements of law and regulation shall govern. the proposed procedure. Microsurgical vascular decompression (MVD) in trigeminal and glosso-vago-pharyngeal neuralgias. Wilkinson HA. service or supply is medically necessary. Sindou M. Trigeminal nerve peripheral branch phenol/glycerol injections for tic douloureux. Health Net does not provide or recommend treatment to members. or subject to dollar caps.58:168-170. Members and providers should refer to the Member contract to determine if exclusions. including medical necessity requirements. service or supply. Mertens P. and services. The member's contract defines which procedure. drug. contact your provider representative. drug. Gamma knife radiosurgery for treatment of trigeminal neuralgia: Idiopathic and tumor related. 1997. conditions. equipment. Policy Amendment without Notice. the contract language prevails. Young RF. drug. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case.

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