CurrentAetnaPolicy 0147

Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD): Diagnosis

Defines Aetna's policy on diagnostic tests and procedures for CRPS/RSD, listing tests considered experimental/investigational (not covered) and referencing the Budapest clinical diagnostic criteria as the preferred diagnostic standard.

Policy Summary

PayerAetna

PolicyComplex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD): Diagnosis

Policy CodePolicy 0147

Change TypeNo material change

Effective DateApr 10, 1997

Next Review DateFeb 8, 2024

Key ActionClinicians should base diagnosis on clinical history and examination using the Budapest Criteria as the preferred diagnostic tool for adults.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

0147Policy Number

1997-04-10Effective Date

2023-07-13Last Review Date

BudapestPreferred Diagnostic Tool (Adults)

MultipleInvestigational tests summarized

Coverage Summary

Defines Aetna's policy on diagnostic tests and procedures for Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD), listing multiple tests considered experimental and investigational (not covered) and referencing the Budapest Criteria as the preferred clinical diagnostic standard. Policy Number: 0147. Effective date: 1997-04-10. Last review: 2023-07-13. Next review: 2024-02-08.

Summary

Policy Number0147

Effective Date1997-04-10

Last Review Date2023-07-13

Next Review Date2024-02-08

Preferred Diagnostic Tool (Adults)Budapest Criteria

Policy Summary

PayerAetna

PolicyComplex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD): Diagnosis

Policy CodePolicy 0147

Change TypeNo material change

Effective DateApr 10, 1997

Next Review DateFeb 8, 2024

Key ActionClinicians should base diagnosis on clinical history and examination using the Budapest Criteria as the preferred diagnostic tool for adults.

SourceLink

On This Page

Experimental, Investigational, and Not Covered Tests

Overall coverage stance is mixed: the policy endorses clinical diagnosis using the Budapest Criteria but considers listed diagnostic tests (e.g., bone SPECT/CT, MRI, MRS, PET, thermography, laser Doppler flowmetry, phentolamine infusion, biomarkers, gene expression profiling, antioxidant profiles, electronic nose/Aeonose, HR‑pQCT, dermal nerve/mast cell measures, and microRNA panels) to be experimental/investigational or without clear diagnostic value because the evidence is insufficient to support their effectiveness for confirming CRPS.

Coding

CPT / HCPCS codes not covered for indications listed in this CPB (examples listed in policy)mixedNot Covered

72170	Radiologic examination, pelvis
72190	Radiologic examination, pelvis (alternate range listed in doc)
73000 - 73140	Radiologic examination, upper extremities
73501 - 73660	Radiologic examination, lower extremities
73218 - 73222	Magnetic resonance imaging, upper extremities
73718 - 73723	Magnetic resonance imaging, lower extremities
76390	Magnetic resonance spectroscopy
76881 - 76882	Ultrasound, extremity, nonvascular, real-time with image documentation; complete or limited, anatomic specific
77078	Computed tomography, bone mineral density study, 1 or more sites, axial skeleton
78811	Positron emission tomography (PET) imaging, limited area (eg, chest, head/neck)

1–10 of 24

1/3

HCPCS drugs not covered for indications listed in this CPBHCPCSNot Covered

J2760

Injection, phentolamine mesylate, [Regitine], up to 5 mg

ICD-10 codes referenced as not covered for indications listed in this CPB (examples provided, not all-inclusive)ICD-10Not Covered

G90.50 - G90.9	Complex regional pain syndrome I (CRPS I) range
M85.80 - M85.9	Other specified disorders of bone density and structure [osteopenia]
S00.00xA - T34.99xS	Injury, poisoning and certain other consequences of external causes (range listed)

Provider Actions & Billing Impact

Documentation Required

Use Budapest Criteria for diagnosis

Clinicians must base the diagnosis of CRPS on a thorough history and physical examination and document findings consistent with the Budapest Criteria. The Budapest Criteria require the presence of continuing pain disproportionate to any inciting event, plus specific signs and symptoms in sensory, vasomotor, sudomotor/edema, and motor/trophic domains on exam and by history.

Document history and physical exam findings that meet Budapest Criteria domains: sensory, vasomotor, sudomotor/edema, motor/trophic.

Denial Risk

Tests considered experimental/investigational — potential denial

Certain tests are considered experimental or investigational because there is insufficient evidence to support their diagnostic utility for CRPS. Claims for these tests may be denied when submitted for CRPS diagnosis.

Examples include: antioxidant profiles (eg, GPX, GST, SOD), biomarkers of inflammation (eg, CGRP, IL-6, TNF‑α), bone SPECT/CT, high-resolution peripheral quantitative CT, gene expression profiling, DNA methylation profiles, electronic nose (Aeonose), magnetic resonance spectroscopy, PET, thermography, laser Doppler flowmetry, measurement of dermal nerve fiber/mast cell density, and musculoskeletal ultrasonography.

Documentation Required

Clinical diagnosis emphasized over testing

Emphasize that CRPS is a clinical diagnosis; document the patient’s history and physical examination findings that align with the Budapest Criteria. Supportive or adjunctive testing does not replace the clinical diagnosis and should not be used as sole justification for diagnosing CRPS.

Ensure documentation clearly shows how the patient meets Budapest Criteria elements and note that supportive testing is adjunctive only.

Background & Evidence Summary

CRPS (formerly RSD) is a regional pain disorder, typically of distal limbs, with sensory, motor, autonomic and trophic disturbances; diagnosis is clinical and based on history and physical examination using the Budapest Criteria. There is no single diagnostic test that confirms CRPS; imaging and other tests may be supportive in doubtful cases but do not replace clinical criteria.

Evidence Item	Result/Value
Bone scintigraphy pooled sensitivity (meta-analysis)
0.87 (95% CI: 0.68-0.97); specificity 0.69 (95% CI: 0.47-0.85)
Bone scintigraphy using Budapest criteria (subgroup)
sensitivity 0.551 (95% CI: 0.046-1); specificity 0.935 (95% CI: 0.306-1)
Thermography sensitivity/specificity (Niehof 2007)
{"text":"sensitivity 71%; specificity 85% (observer assessment); overall reliability/repeatability low"," status":""}
Thermography in early CRPS (Gradl 2003)
thermography sensitivity 58%; specificity 66% (poor sensitivity overall)
Aeonose pilot study sensitivity/specificity
sensitivity 83% (95% CI 67-93%), specificity 78% (95% CI 60-89%), accuracy 81% (n=72)
Bone scintigraphy conclusion
BS cannot be used to confirm CRPS 1; negative BS makes CRPS 1 less likely
HR-pQCT findings
CRPS-affected distal tibiae show lower cortical BMD and cortical thickness; increased bone resorption implicated
PET ([11C]-(R)-PK11195) pilot
Increased DVR in basal ganglia and thalamus in CRPS vs controls (small sample)
Selected references
Multiple citations listed including Wasner et al. 2003; Wertli et al. 2017; Wijaya et al. 2022

Definitions

Term	Definition
CRPS Type I (RSD)
CRPS without evidence of peripheral nerve injury (represents ~90% of cases).
CRPS Type II (causalgia)
CRPS with evidence of peripheral nerve injury.
Budapest Criteria
Clinical diagnostic criteria recommended for diagnosis of CRPS in adults; requires disproportionate continuing pain, symptoms in sensory, vasomotor, sudomotor/edema, and motor/trophic categories, signs in ≥2 categories, and exclusion of other diagnoses; referenced as preferred diagnostic tool.

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