Prior authorization required for listed CRPS procedure codes

Prior authorization is required for the CPT/HCPCS codes listed in the policy when used for CRPS treatments and only when the policy’s selection criteria are met. Refer to the listed codes (e.g., 01996, 62324–62327, 63650, 63655, 63661–63664, 63685, 63688, 64479, 64510–64530, L8680–L8688, etc.) when submitting requests.

• Prior authorization applies only when selection criteria in this Clinical Policy Bulletin are not met, or when implant/testing of neuromodulation is planned.
• Supply documentation that demonstrates the member meets the applicable selection criteria in the policy.

Recommend prior authorization for high‑resource interventions

For resource-intensive interventions (for example, multi-day ketamine infusions, spinal cord or DRG stimulation, intrathecal pumps), prior authorization is recommended and requests should document refractory disease and prior therapies attempted.

• Include evidence of failed conservative management and rationale for escalation.
• Resource-intensive outpatient infusions should note supervising clinician and monitoring plans.

Prior authorization appropriate for multi‑day IV ketamine and IV therapies

Prior authorization is appropriate for multi-day IV ketamine infusions and other IV therapies in chronic refractory CRPS; requests should include documentation of prior conservative therapy failures and indicate the treatment is for selected, refractory patients.

• Provide baseline pain scores and monitoring plan (e.g., continuous ECG, pulse oximetry, BP monitoring every 15 minutes as in outpatient infusion studies).
• Document prior conservative therapy attempts and why IV therapy is being considered.

DRG stimulation requires prior conservative failure and trial documentation

Dorsal root ganglion stimulation (DRGS) requests should document prior conservative management failure and evidence of a successful trial stimulation (trial outcome, targeted levels) before permanent implantation.

• Document trial stimulation results (e.g., proportion pain relief, VAS/NRS scores) and absence of stimulation‑related neurological deficits.
• Indicate targeted DRG levels (e.g., L2–L4 for knee CRPS) and prior conservative therapies attempted.

Document trial stimulation success and outcome measures for DRG implantation

When seeking permanent DRG stimulation implantation, document successful trial stimulation and provide trial‑to‑implantation outcome measures (e.g., percentage pain relief, VAS/NRS), because DRG implant decisions are supported by trial data and case series.

• Cite trial success thresholds when available (ACCURATE trial used ≥50% VAS decrease as an efficacy threshold).
• Include follow‑up outcome measures if prior implants/trials exist.

Neuromodulation implantation usually requires prior trial documentation

Requests for implantation of neuromodulation devices (DRG stimulator, spinal cord stimulator, percutaneous PNS) typically require documentation of prior trial success and failure of conservative therapies; provide device trial data and relevant prior therapy history.

• Attach trial stimulation reports, pain scores, and evidence of prior conservative management failure (PT, medications, etc.).
• For novel/combined device approaches, include supporting case series or trial data when available.

No additional authorization process specified in this excerpt

This excerpt does not list specific plan-level prior authorization forms, portals, or additional affected codes beyond those listed in the CPT/HCPCS tables; check member benefits and utilization management procedures for any payer‑specific prior authorization processes.

• Policy text notes that Clinical Policy Bulletins assist in administering benefits but do not guarantee coverage; follow plan-specific authorization channels.

Document prior conservative therapy and failed PT before advanced interventions

Providers must document trials of conservative therapy — including exercises, physical modalities, and medications — and a failed trial of physical therapy before considering continuous epidural analgesia or sympathetic interventions.

• Document duration of pain (>3 months) and specific conservative therapies tried and their durations.
• For sympathetic blocks, note that conservative treatments (including analgesia and PT) must have failed prior to initial trial injections.

Document prior attempts of evidence‑backed conservative therapies

The policy emphasizes consideration of evidence‑backed conservative therapies (e.g., bisphosphonates, motor/sensory learning programs) and documents prior attempts at these therapies before proceeding to experimental or high‑risk interventions.

• If bisphosphonates or motor imagery programs were tried, include treatment dates, dosing, and response.
• Explain why other evidence‑backed conservative measures were insufficient in refractory cases.

Adopt a conservative‑first approach before interventional therapy

Guidance reflects a conservative‑first approach: initial conservative management including analgesics and physical therapy should be attempted before considering sympathetic blocks, sympathectomy, or other invasive procedures.

• State which conservative therapies were used and the duration of each.
• Use Budapest Criteria documentation to confirm diagnosis prior to invasive therapies when applicable.

Document trials of movement representation and physiotherapy before invasive procedures

Conservative therapies such as graded motor imagery, mirror therapy, and physiotherapy‑based interventions are reasonable early options prior to invasive procedures; document trial and response to these modalities when claiming refractory status.

• Provide details of motor imagery or mirror therapy programs (duration, frequency) and measured outcomes.
• Note that evidence quality is low to very low, but these are recommended conservative options before invasive therapy.

No explicit step‑therapy sequences specified in this excerpt

The policy excerpt does not define explicit step therapy sequences or mandated order of conservative therapies; there are no prespecified step therapy requirements in this portion of the document.

• While no mandated sequences are provided, document prior conservative therapies and rationale for chosen escalation pathways.
• Providers should still supply evidence of attempted conservative care when requesting advanced interventions.

Provide prior conventional therapy attempts before adjunctive/novel therapies

The document expects that adjunctive or novel therapies be considered after standard therapies; provide documentation of prior attempts and responses to conventional treatments before requests for experimental or combined approaches.

• For combined DRG and DCS or novel device use, include supporting trial/case series evidence and prior standard therapy history.
• Explain why standard interventions (PT, medications) were inadequate.

Step therapy requirements not specified in this section

The policy expressly notes that no formal step therapy requirements are described in this portion of the bulletin; absence of step therapy language means clinicians must still document prior conservative care but are not bound to a mandated sequence here.

• Confirm any payer‑specific step therapy rules separately, as this bulletin does not establish them.
• Provide complete conservative treatment history with authorization requests.

Required clinical documentation: pain history, conservative therapy, and block results

Clinical documentation must include duration of pain, prior conservative therapies (exercises, PT, medications), results of nerve block trials, and enrollment in a comprehensive pain management program when repeat sympathetic blocks or continuous epidural analgesia are requested.

• For continuous epidural analgesia, confirm pain >3 months, failed PT, and failed nerve block trials.
• When requesting repeat sympathetic blocks beyond three injections, include evidence of the comprehensive pain program components.

Document prior conservative failure and treatment‑resistant designation for refractory therapies

When requesting refractory treatments such as anesthetic‑dose ketamine or DRGS, include detailed documentation of prior conservative treatment failure, designation of treatment‑resistant status, and specific dosing/course details for infusions.

• For ketamine infusions, include infusion duration, dose escalation plan, and prior conservative therapies attempted.
• State why the patient qualifies as treatment‑resistant or refractory.

Documentation required for IV therapy requests: baseline scores and monitoring

For IV therapies (e.g., ketamine), include objective baseline pain scores and functional measures and monitoring details because many IV therapy trials enrolled refractory patients with documented baseline measures.

• Provide baseline VAS/NRS scores and functional assessments.
• Describe monitoring during infusion (ECG, pulse oximetry, BP monitoring frequency) as used in outpatient protocols.

Provide supporting documentation: diagnosis, prior treatments, and trial outcomes

Recommended supporting documentation for advanced or investigational interventions includes prior conservative therapy attempts, CRPS diagnosis consistent with Budapest Criteria, prior treatment failures, and trial stimulation outcomes for device requests.

• Attach Budapest Criteria assessment or equivalent documentation to support diagnosis.
• Include trial stimulation outcomes, percentage pain relief, and device‑related follow‑up when applicable.

Include clinical trial evidence and outcome measures for investigational device requests

When requesting DRG stimulation or other investigational interventions, include clinical trial evidence and outcome measures (e.g., VAS/NRS scores, percentage pain relief, trial‑to‑permanent success) to support the request.

• Reference available RCT or cohort evidence where applicable (ACCURATE trial for DRGS used ≥50% VAS reduction threshold).
• Supply device trial reports and follow‑up outcome data.

Document CRPS diagnosis using Budapest Criteria

Clinical documentation must support a CRPS diagnosis using the Budapest Criteria (documenting symptoms and signs across sensory, vasomotor, sudomotor/edema, and motor/trophic categories and exclusion of alternate diagnoses).

• Include recorded signs/observations and reported symptoms that map to Budapest Criteria categories.
• Document exclusion of other diagnoses that better explain the findings.

Administrative note — policy bulletins do not guarantee coverage

Clinical Policy Bulletins assist in benefit administration and do not guarantee coverage; treating providers remain responsible for medical advice and must follow plan‑specific authorization and documentation requirements.

• Policy statements do not constitute contract or guarantee of benefits; verify member benefits and authorization requirements separately.

Denial risk if epidural analgesia criteria not met

Continuous epidural analgesia is medically necessary only when all selection criteria are met (pain >3 months despite conservative therapy, failed PT, failed nerve blocks); otherwise it is considered experimental/investigational and may be denied.

• Ensure documentation demonstrates each required selection criterion before billing for continuous epidural analgesia.
• If criteria are not met, expect the treatment to be considered experimental/investigational and at risk for denial.

Denial risk for excessive sympathetic block frequency or lack of benefit

Sympathetic blocks beyond three injections without documented therapeutic benefit, or repeated outside a comprehensive pain program, may be denied; do not repeat more frequently than once every 7 days.

• Initial trial limited to up to 3 injections to establish diagnosis/therapeutic effect.
• If no relief after three injections, additional injections are not medically necessary and may be denied.

Denial risk for therapies without well‑designed RCT evidence

Treatments lacking supportive RCT evidence (many interventions reviewed) may be considered unsupported by evidence and are subject to denial if billed as proven therapies; provide high‑quality evidence when seeking coverage for such interventions.

• Interventions without adequate RCT support (e.g., numerous listed investigational therapies) should include supporting peer‑reviewed evidence in requests.
• Expect additional review or denial when robust evidence is absent.

Denial risk for sympathectomy without clear prior therapy failure

Sympathectomy (chemical or surgical) should be used cautiously and generally only after failure of other treatment options; lack of high‑quality evidence may lead to denial if attempted earlier or broadly.

• Because randomized, controlled evidence is minimal, justify sympathectomy with prior conservative treatment failure and case‑by‑case rationale.
• Anticipate careful review and potential denial without documented prior management attempts.

Evidence limitations may trigger additional review or denial

Evidence limitations — including high heterogeneity, variable dosing/duration, small sample sizes, and short‑term benefits (e.g., ketamine pain relief often <3 months) — may trigger documentation requests or denial for routine coverage without supporting clinical rationale.

• Meta‑analyses and systematic reviews note heterogeneity and short duration of effect for IV ketamine; include clinical rationale and monitoring data.
• Provide long‑term outcome data where available to support coverage.

No specific authorization/coding denial triggers listed here

The excerpt does not specify explicit authorization or coding‑based denial triggers beyond the general statements above; verify payer‑specific coding and authorization policies.

• No additional coding‑based denial triggers are specified in this portion of the policy.
• Confirm plan‑specific utilization management rules when submitting claims.

Insufficient peer‑reviewed evidence may lead to denial for proprietary devices

Lack of peer‑reviewed published data for certain proprietary devices or novel therapies (e.g., Sanexas electroanalgesia) may lead to noncoverage or denial when billed without supporting evidence.

• When proposing use of devices with limited peer‑reviewed data, include any available studies and justify clinical rationale.
• Expect denials in the absence of published supporting evidence.

No administrative denial triggers specified; verify plan applicability

Administrative denial risks are not detailed in this section; policy history and review dates are provided which may affect applicability — check plan dates and member benefits for current applicability.

• Policy last reviewed 02/27/2024; verify member eligibility and policy version at time of service.
• Administrative or benefit‑limit denials are managed per plan documents, not by this CPB text alone.

Use fluoroscopy/CT for specified epidural, transforaminal, and neurostimulator procedures

Epidural injections, transforaminal injections, and neurostimulator electrode placement codes indicate imaging guidance (fluoroscopy or CT) where specified in coding descriptors; perform and document imaging guidance for those codes.

• 62327 and 64479–64484 specify fluoroscopy or CT guidance.
• Neurostimulator electrode placement codes reference fluoroscopy when performed.

Monitoring requirements during ketamine infusions (ECG, SpO2, BP q15min)

Ketamine infusion protocols described in outpatient studies included continuous ECG, pulse oximetry, and non-invasive blood pressure monitoring every 15 minutes during infusions; document monitoring used.

Obtain MRI as indicated to exclude alternative diagnoses

MRI may be useful to exclude alternative diagnoses and should be used as part of the diagnostic workup when indicated; document imaging findings when used to support CRPS evaluation.

Document DRGS lead placement and targeted levels

DRGS implantation documentation should include lead placement details and the targeted levels (e.g., lumbar leads for knee CRPS such as L2–L4) and report trial stimulation results.

• Document number and location of percutaneous leads.
• Include trial outcome and programming/coverage notes.

DRG lead placement: document percutaneous technique and imaging guidance

DRG lead placement in published series used conventional percutaneous techniques with imaging guidance implied; when applicable document imaging guidance and lead targeting.

Use and document imaging guidance for percutaneous PNS when performed

For percutaneous peripheral nerve stimulation (PNS), published reports recommend using imaging (e.g., ultrasound) when described; document imaging guidance if used for needle/lead placement.

No general imaging prerequisites specified — follow procedure-specific guidance

No specific imaging prerequisites are provided in this part of the document for other therapies; follow code descriptors and local standards and document any imaging performed.