Medicare prior authorization · 64605

64605 — Induced Lesions of Nerve Tracts

Subject to WISeR prior authorization or pre-payment review in AZ, NJ, OH, OK, TX, WA for dates of service 2026-01-15 through 2031-12-31, in hospital outpatient, ambulatory surgical center, office and home settings. The decision is made on Medicare’s existing coverage policy; nothing in these programs changes what is covered.

WISeR

Decision: 3 days; 2 days expedited; unlimited resubmissions
If no request is made: the claim goes to pre-payment medical review
Policies CMS cites (Appendix A): NCD 160.1
Participant by state: AZ: Zyter · NJ: Genzeon · OH: Innovaccer · OK: Humata Health · TX: Cohere Health · WA: Virtix Health
Exemption: NPI-level, after ≥10 requests and the participant’s affirmation-rate threshold in an assessment period; granted quarterly from July 2026; held at least a year.

What CMS lists for the record

From the WISeR Operational Guide, verbatim. The coverage policy governs; use the check below for the diagnosis and state.

CMS WISeR documentation checklist · §6.2.2

Operational Guide v7.0, last updated July 24, 2026 · retrieved 2026-09-14

Induced Lesions of Nerve Tracts (NCD 160.1)

CMS: “To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity of services. Subsections 6.2.1 to 6.2.13 list the documentation requirements for example services. For detailed documentation requirements, providers who choose to submit a prior authorization request for a WISeR Select Item or Service should refer to the relevant NCDs and/or their MAC jurisdiction’s LCDs and Local Coverage Articles (LCAs), if available, for guidance. They can be found on the Medicare Coverage Database website.”

For this NCD, WISeR will initially focus on neurolytic destruction of the trigeminal nerve. General documentation requirements are as follows:

Documentation of diagnosis and evaluation of trigeminal neuralgia, including history (of compatible clinical features and impact on daily function) and imaging, as applicable
Documentation of failure of or intolerance to conventional medications (e.g., carbamazepine, oxcarbazepine, gabapentin)
Documentation of the clinical rationale (e.g., patient cannot tolerate open surgery, patient does not have signs of neurovascular compromise) supporting the selection of rhizotomy or neurolysis over other surgical options (e.g., microvascular decompression, stereotactic radiosurgery)

Read the guide on CMS →

The coverage policy the reviewer applies, by state

Each state’s Medicare contractor writes its own LCD, so the policy that decides a 64605 request depends on the state. The documentation requirements below are quoted from the policy or its Billing & Coding article as captured; the linked CMS document is authoritative.

All WISeR states (AZ, NJ, OH, OK, TX, WA) · national coverage determination

NCD 160.1 — Induced Lesions of Nerve Tracts · CMS version 1 · captured 2026-09-13

Read the documentation requirements in the linked CMS document.

Check 64605 for your state, diagnosis and setting

The governing policy as it stands today, whether the diagnosis is on its list, and the documentation the policy’s own text requires — quoted, source-linked, free.

Run the check →

Full lists: WISeR code list · WISeR rules and exemption

Same family: 64610

Sources: CMS WISeR Provider and Supplier Operational Guide v7.0 (2026-07-24), Appendix A; CMS list of OPD services requiring prior authorization (2024-08-05); CMS list of ambulatory surgical center services for prior authorization (2026-03-05) and the ASC Operational Guide (2026-03-03). Codes are shown as numbers only, as CMS lists them. CPT® is a registered trademark of the American Medical Association.