CurrentAmbetter NevadaPolicy CP.MP.170

Nerve Blocks and Neurolysis for Pain Management

Defines medical necessity, coverage criteria, and limitations for a range of peripheral and sympathetic nerve blocks and neurolysis procedures for non‑Medicare Ambetter Nevada members, including diagnostic and therapeutic uses and indications where treatment is not supported.

Policy Summary

PayerAmbetter Nevada

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document prior conservative therapy and response to diagnostic injections to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤1procedure limit per visit

≤4occipital injections /12 mo

≥3wsympathetic conservative trial

≥3mceliac repeat interval

insufficientbasivertebral evidence

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Coverage Criteria for Peripheral and Sympathetic Nerve Procedures

inv-01: Occipital Nerve Block — Diagnostic

Covered when ALL of the following are met:

Occipital diagnostic: Initial injection is medically necessary when: 1) patient has unilateral or bilateral pain located in the distribution of the greater, lesser and/or third occipital nerves; 2) pain has at least two of the following characteristics: recurring paroxysmal attacks, severe intensity, or shooting/stabbing/sharp quality; 3) pain is associated with dysesthesia and/or allodynia on innocuous stimulation of the scalp and/or hair, and at least one of: tenderness over the affected nerve branches or trigger point at the emergence of the greater occipital nerve or in the distribution of C2.

inv-02: Occipital Nerve Block — Therapeutic

Covered when ALL of the following are met:

Occipital therapeutic: Therapeutic occipital nerve blocks are medically necessary when: 1) there was temporary relief from the initial/previous injection as evidenced by reduction in numeric rating scale pain score; 2) the member has failed three months of conservative treatment including: heat/rest/physical therapy (including massage); NSAIDs unless contraindicated; oral anticonvulsants (e.g., carbamazepine, gabapentin, pregabalin) or tricyclic antidepressants; and activity modification to address triggers; 3) no more than four injections are given within 12 months (includes diagnostic injection).no more than 4 injections per 12 months

inv-04: Celiac Plexus Nerve Block/Neurolysis

Covered when ANY of the following specific indications are met:

Pancreatic cancer indication: Chronic neuralgic pain secondary to pancreatic cancer when: a) diagnosis of pancreatic cancer with severe visceral abdominal or back pain; b) strong analgesics (opioids) are no longer effective or their side effects decrease quality of life; c) no malignancy in an area of somatic innervation such as the peritoneum or diaphragm.

Chronic pancreatitis indication: Refractory pain due to chronic pancreatitis with a non-dilated pancreatic duct.

inv-05: Celiac Plexus Repeat Criteria

Covered when ALL of the following are met:

Celiac repeat for chronic pancreatitis: Repeat celiac plexus nerve block for refractory pain from chronic pancreatitis with nondilated pancreatic duct is medically necessary when: 1) at least three months have passed since the previous injection; and 2) there was clinical benefit from the initial celiac block (e.g., alleviation or reduction of abdominal pain or elimination of need for oral analgesia).>=3 months since prior injection

inv-06: Intercostal Nerve Block/Neurolysis

Covered when ALL of the following are met:

Intercostal nerve block/neurolysis is medically necessary for chronic neuralgic pain secondary to an injured intercostal nerve (e.g., rib fracture, thoracotomy incision) or chronic post-herpetic neuralgia or other neuropathic process when: 1) a suspected organic problem exists; 2) non-responsiveness to conservative modalities of treatment; 3) pain and disability are of moderate to severe degree; and 4) no contraindications such as infection or predominantly psychogenic pain.

inv-07: Peripheral/Ganglion Nerve Blocks

Covered when ALL of the following specific indications are met:

Malignant pain: Peripheral nerve blocks for diagnosis and treatment of malignant pain are medically necessary as part of a comprehensive pain management program.

Post-herniorrhaphy diagnostic: A first diagnostic peripheral nerve block for post-herniorrhaphy neuralgia is medically necessary when: 1) diagnosis of post-herniorrhaphy neuralgia; 2) groin pain has persisted for three months after surgical hernia repair; 3) less invasive pain management methods (NSAIDs and/or opiates) have not relieved the pain; 4) imaging studies have ruled out non-neuropathic causes; and 5) documentation indicates pain is not attributable to any other cause.>=3 months since repair

Post-herniorrhaphy therapeutic: Therapeutic peripheral nerve block(s) for post-herniorrhaphy pain are medically necessary when: 1) there was temporary relief from the initial/previous injection; and 2) injections are given at least one week apart.>=1 week between injections

inv-08: Neurolysis / Celiac Plexus Blocks

Covered when clinical criteria are met for the specific indications below:

Celiac plexus neurolysis for pancreatic cancer: Celiac plexus neurolysis for pain associated with advanced pancreatic cancer is supported by evidence demonstrating reduced opioid use and pain; pooled pain relief with EUS-guided neurolysis is reported at approximately 53–80%, though optimal timing is uncertain and repeat neurolysis is effective in only about 30% of cases and is not recommended.

Celiac plexus block for chronic pancreatitis: Celiac plexus blockade is an option for refractory pain in chronic pancreatitis with a non-dilated pancreatic duct; pain relief is typically transient (approximately 3–6 months) and the American College of Gastroenterology gives a conditional recommendation based on very low quality evidence.

inv-09: Intercostal and Thoracic Blocks

Covered when clinical criteria are met for thoracic/intercostal indications:

Intercostal nerve blocks for chest/upper abdominal pain: Intercostal nerve blocks may be used for chest and upper abdominal pain (e.g., rib fractures, post-herpetic neuralgia). Initial management for isolated injuries is NSAIDs with or without opioids; blocks are indicated for more severe injuries (e.g., compromised ventilation) or when multiple rib fractures require multiple levels. Repeated blockade may be needed for prolonged relief when prior response demonstrated by improved physical and functional status.

inv-10: Peripheral/Ganglion Nerve Blocks

Covered as part of multimodal management when clinical indications met:

Genicular nerve procedures and peripheral blocks for focal pain: Genicular nerve blocks and radiofrequency neurotomy are emerging with limited and conflicting evidence; peripheral nerve blocks are used for surgical anesthesia, postoperative analgesia, chronic focal pain, and cancer-related pain as part of a comprehensive multimodal program. Optimal candidates have focal pain of shorter duration, appropriate expectations, and managed psychosocial distress.

Post-herniorrhaphy groin pain management: For post-herniorrhaphy groin pain, suspect neuralgia after 6–8 weeks; imaging should exclude non-neuropathic causes and patients with positive response to an initial nerve block may receive repeat blocks every 1–3 weeks until sustained relief is achieved.repeat every 1-3 weeks if initial positive response

inv-11: Basivertebral Nerve Ablation

Covered when ALL of the following are met:

Basivertebral nerve ablation (Intracept): Intended for chronic low back pain of at least six months' duration that has not responded to at least six months of conservative care, and with MRI findings consistent with Type 1 or Type 2 Modic changes. The device (Intracept) is FDA-cleared; evidence is limited and guideline support is mixed.>= 6 months conservative care

Occipital nerve block for the diagnosis or treatment of other headache types, including migraine and cervicogenic headaches, is considered not medically necessary because effectiveness has not been established.

Sympathetic nerve blocks for any indication other than the specified CRPS criteria (for example, ischemic limb pain) are considered not medically necessary due to lack of evidence supporting effectiveness.

Peripheral nerve blocks used for the prevention or treatment of headaches (including migraine and similar primary headache syndromes) are considered not medically necessary because current evidence is limited and effectiveness has not been established.

Genicular nerve blocks, neurolysis, and genicular radiofrequency neurotomy, as well as intraosseous radiofrequency ablation of the basivertebral nerve, have insufficient evidence to determine safety and effectiveness; available studies are limited and conflicting, and these procedures are not supported as standard therapy at this time.

Inclusion or exclusion of procedure codes in the coding tables is informational only and does not by itself guarantee coverage or payment; providers must follow current coding guidance and payer authorization requirements when submitting claims.

Coverage determinations under this policy are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents. When state Medicaid provisions conflict with this policy, state Medicaid provisions take precedence.

Additional sympathetic nerve blocks beyond the first or second are not medically necessary when there is no documented benefit from the initial blocks; repeat blocks should only be considered if given at least one week apart and there was an immediate positive response to the prior block(s).

Peripheral nerve blocks for the prevention or treatment of headaches (including migraine) are considered not medically necessary because evidence supporting their use for headache prevention or treatment is limited and inconclusive.

Genicular nerve procedures and intraosseous radiofrequency ablation of the basivertebral nerve are considered to have insufficient evidence for safety and effectiveness and therefore are not supported as established treatments based on current peer‑reviewed literature.

Policy history and revision notes document prior changes in indications (for example, reclassification of ischemic leg pain to not medically necessary); consult the full policy history and current criteria for complete context when reviewing prior decisions.

Procedure and Reference Codes

Covered CPT Codes (injection procedures)CPTCovered

64400	Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular).
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve.
64408	Injection(s), anesthetic agent(s) and/or steroid; vagus nerve.
64415	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed.
64417	Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed.
64418	Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve.
64420	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level.
64421	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level.
64425	Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves.
64430	Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve.

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Covered CPT Codes (neurolysis/ablation)CPTCovered

64454	Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed.
64505	Injection, anesthetic agent; sphenopalatine ganglion.
64510	Injection, anesthetic agent; stellate ganglion (cervical sympathetic).
64517	Injection, anesthetic agent; superior hypogastric plexus.
64520	Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic).
64530	Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring.
64600	Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch.
64605	Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale.
64610	Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring.
64620	Destruction by neurolytic agent, intercostal nerve.

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Referenced Medicare LCD/LCA identifiersmixed

L36850	Local coverage determination: peripheral nerve blocks
L39420	Local coverage determination: thermal destruction of the intraosseous basivertebral nerve (BVN)
A57788	Local coverage article: peripheral nerve blocks
L33933	Local coverage determination: peripheral nerve blocks

FDA 510(k) referencemixed

K190504

FDA 510(k) Premarket Notification for Intracept Intraosseous Nerve Ablation System (reference PDF ID)

inv-26: Duration of conservative care before basivertebral nerve ablation — required duration

Required duration of conservative care>= 6 months of conservative care prior to basivertebral nerve ablation

Clinical imaging requirementMRI findings consistent with Type 1 or Type 2 Modic changes required to support procedure

Indication durationChronic low back pain of at least 6 months duration

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization and Procedure Limits

Invasive pain management procedures are limited to one procedure per visit; prior authorization may be required by the Health Plan. Providers should verify prior authorization requirements with the member’s specific plan and follow applicable Health Plan administrative policies and Medicare guidance where relevant.

One invasive procedure per visit policy applies to non‑Medicare plans affiliated with Centene.
Prior authorization requirements vary by plan — check member benefits and Health Plan administrative rules before scheduling.

Billing Rule

Coding Inclusion Is Not a Guarantee of Coverage

Inclusion of CPT or other procedure codes in this clinical policy does not guarantee coverage or payment. Providers must confirm current coding guidance and billing rules and ensure services are consistent with the member’s contract, applicable exclusions, and limitations.

Coding in this policy is informational only; verify coding edits, bundling rules, and modifier requirements prior to claim submission.
Coverage is subject to the member’s evidence of coverage/certificate of insurance and to state and federal requirements.

Documentation Required

Occipital Block Documentation

For occipital nerve blocks, document that the initial or prior diagnostic/therapeutic injection produced temporary relief — for example, a patient‑reported reduction in numeric rating scale (NRS) pain score. Also document failed conservative therapy as required (see conservative therapy callout).

Record pre‑ and post‑injection pain scores (e.g., NRS) to demonstrate temporary relief from the diagnostic injection.
Document the clinical rationale linking relief from the injection to the targeted occipital nerve distribution.

Documentation Required

Documentation of Medical Necessity

Providers should document that services meet the clinical criteria in this policy and any applicable coverage documents. Documentation must support medical necessity and include diagnosis, prior conservative therapies, response to prior injections when applicable, timing intervals between injections, and objective findings when relevant.

Include diagnosis, relevant history, and clinical findings (e.g., tenderness, allodynia, temperature changes).
Detail prior conservative treatments tried and their duration, and document objective/subjective response to prior nerve blocks.
If repeating blocks, document benefit from the initial block and adherence to required interval thresholds (e.g., ≥3 months for repeat celiac plexus for chronic pancreatitis; ≥1 week between sympathetic or peripheral therapeutic blocks as specified).

Step Therapy

Conservative Therapy Requirement

Therapeutic nerve blocks (including occipital and sympathetic blocks where indicated) require documentation of failure of specified conservative treatments prior to approval. Conservative therapy components vary by indication and must be present in the medical record.

Occipital nerve block: failed ≥3 months of conservative treatment including heat/rest/physical therapy, NSAIDs (unless contraindicated), oral anticonvulsant or tricyclic antidepressant therapy, and activity modification.
Sympathetic nerve block for CRPS: failed ≥3 weeks of conservative therapies (activity modification, exercise, topical agents, oral medical management) and participation in active rehabilitation.
Peripheral post‑herniorrhaphy blocks: trial of less invasive measures such as NSAIDs and/or opioids and imaging to exclude non‑neuropathic causes prior to diagnostic block.

Required Conservative Care Before Interventional Procedures

inv-47: Documented failure of specified conservative therapy prior to therapeutic block — occipital 3 months; sympathetic >=3 weeks

Covered when ALL of the following conservative therapy documentation requirements are met prior to approval of a therapeutic nerve block:

Occipital therapeutic conservative requirement: For therapeutic occipital nerve block: documented failure of three months of conservative therapy including heat/rest/physical therapy (including massage), NSAIDs (unless contraindicated), oral anticonvulsants or tricyclic antidepressants, and activity modification.Occipital: >= 3 months

Sympathetic (CRPS) conservative requirement: For sympathetic nerve blocks for CRPS: documented failure of at least three weeks of conservative therapies such as activity modification, exercises, topical lidocaine or capsaicin, and oral medical management (NSAIDs, antidepressants, anticonvulsants, glucocorticoids).Sympathetic: >= 3 weeks

General conservative therapies expectation: Providers are expected to follow generally accepted standards of medical practice and evidence-based guidelines prior to interventional procedures, and document prior conservative care per those standards.

inv-48: Document prior conservative care for >=6 months — baseline requirement for some procedures (e.g., basivertebral ablation)

Covered when ALL of the following are met:

Basivertebral conservative documentation: Basivertebral nerve ablation candidates must have documented prior conservative care for at least six months without adequate improvement before consideration for the procedure.>= 6 months prior conservative care

Procedure Frequency and Interval Limits

inv-50: Occipital nerve injections — maximum of four injections

Maximum number of occipital injectionsNo more than four injections within 12 months (includes diagnostic injection)

Documentation for therapeutic useTherapeutic use requires temporary relief from prior injection and failure of 3 months conservative therapy

Conservative therapy componentsHeat/rest/physical therapy, NSAIDs unless contraindicated, oral anticonvulsants or TCAs, activity modification

inv-51: Additional sympathetic nerve blocks — when considered, blocks given at least one week apart

Minimum interval between sympathetic blocksBlocks must be given at least one week apart

Response required to consider additional blocksImmediate positive response to first or second block (e.g., improved temperature >=1.5°C and decreased pain)

Denial conditionAdditional sympathetic blocks without documented benefit from first or second are not medically necessary

inv-52: Celiac plexus block for chronic pancreatitis — repeat allowed after 3 months

Minimum interval for repeat celiac plexus block (chronic pancreatitis)>= 3 months since previous injection

Clinical benefit requirement for repeatThere must have been clinical benefit from the initial celiac block (e.g., alleviation/reduction of abdominal pain or elimination of need for oral analgesia)

Indication for initial procedureRefractory pain due to chronic pancreatitis with non-dilated pancreatic duct

inv-53: Celiac plexus neurolysis — repeat effectiveness ~30%; repeat not routinely recommended

Effectiveness of repeat neurolysisRepeat celiac plexus neurolysis effective only about 30% of the time

Recommendation on routine repeatsRepeat neurolysis is not recommended due to limited effectiveness

Pooled pain relief for initial EUS-guided neurolysisPooled pain relief reported at 53–80% for pancreatic cancer patients

inv-54: Groin nerve blocks/post-herniorrhaphy blocks — repeat every 1–3 weeks if initial positive response

Repeat interval for groin/post-herniorrhaphy blocksCan be repeated every 1–3 weeks if initial positive response

Initial diagnostic timingPost-herniorrhaphy neuralgia suspected if pain persists beyond 6–8 weeks; positive initial block may guide therapy

Imaging requirementPatients should undergo imaging to exclude non-neuropathic causes before nerve block interventions

Imaging Guidance and Procedural Imaging Recommendations

Note

Imaging optional for invasive pain procedures

Imaging for invasive pain management procedures is optional and procedures may be performed with or without radiographic guidance per clinician judgment.

Policy states procedures are medically necessary when criteria met, with or without radiographic guidance
One procedure allowed per visit

Note

Use imaging guidance when clinically indicated for specified procedures

Use imaging guidance as clinically indicated for intercostal blocks, genicular procedures, basivertebral ablation, and peripheral blocks; many CPT descriptions include imaging guidance when performed.

Ultrasound may reduce complications for intercostal blocks
CPT descriptions for genicular, basivertebral, and other codes reference imaging guidance

Note

Follow referenced LCA/LCD and procedural imaging standards

Adhere to procedural and imaging guidance referenced in the policy and in applicable Medicare Local Coverage Determinations and coverage articles when performing peripheral nerve procedures and intraosseous ablation.

References and LCD/LCAs imply adherence to procedural standards
Review CMS Local Coverage Articles and Determinations as applicable

Procedures and Indications Considered Not Medically Necessary

Not covered examples include: occipital nerve block for migraine or cervicogenic headache, sympathetic nerve blocks for ischemic limb pain and other unsupported indications, and peripheral nerve blocks for prevention or treatment of headaches; these are listed because effectiveness has not been established for these uses.

Additional not‑covered statements clarify that repeat sympathetic blocks without benefit will be denied and that coding tables do not ensure coverage — providers should verify authorization requirements and document clinical benefit when seeking additional procedures.

Peripheral nerve blocks for trigeminal neuralgia and for prevention or treatment of headaches (including migraine) lack sufficient evidence and are considered investigational or not medically necessary for these indications.

Genicular nerve blocks, neurolysis, genicular radiofrequency neurotomy, and intraosseous basivertebral nerve RFA are considered unsupported due to insufficient published evidence and are therefore not covered for routine treatment of chronic pain conditions.

Evidence for peripheral nerve blocks in headache disorders is limited to small series and inconsistent findings; larger, controlled studies are necessary before these indications can be supported as covered therapies.

Background and Rationale

Nerve blocks temporarily interrupt peripheral nerve conduction by injecting local anesthetic and can serve diagnostic or therapeutic roles; specific indications and limitations vary by block type and the available evidence.

Definitions

inv-42: Definition — Nerve block

DefinitionTemporary interruption of conduction of impulses in peripheral nerves or nerve trunks by injection of local anesthetic solutions

UsesCan be diagnostic to identify pain source or therapeutic to treat pain

MechanismLocal anesthetic injection interrupts peripheral nerve conduction temporarily

inv-51: Definition — Occipital neuralgia

DefinitionOccipital neuralgia: unilateral or bilateral paroxysmal, shooting or stabbing pain in the posterior scalp in distribution of greater, lesser, or third occipital nerves

Associated findingsMay be accompanied by diminished sensation or dysesthesia and commonly tenderness over involved nerve(s)

Diagnostic criterionRelief of pain following local anesthetic block is part of IHS diagnostic criteria for occipital neuralgia

inv-52: Definition — Genicular nerve block / radiofrequency neurotomy

DefinitionProcedures targeting sensory genicular nerves around the knee to address joint pain (genicular nerve block, neurolysis, radiofrequency neurotomy)

Evidence statusEmerging interventions with limited and conflicting evidence for predictive value and efficacy

Clinical useMay be considered for knee pain, but further research needed to establish safety and efficacy

inv-53: Definition — Basivertebral nerve ablation (Intracept)

DefinitionThermal intraosseous radiofrequency ablation of the basivertebral nerve intended to treat chronic low back pain associated with vertebral endplate (Modic) changes

Indication summaryFor chronic low back pain ≥6 months not responsive to ≥6 months conservative care with MRI features consistent with Type 1 or Type 2 Modic changes

Evidence summaryCurrent studies report pain relief and functional improvement but are mostly company-sponsored and of limited quality; guideline support is weak and mixed

inv-54: Definition — Intracept intraosseous nerve ablation system (FDA 510k)

Device regulatory statusIntracept Intraosseous Nerve Ablation System is FDA 510(k)-cleared for intraosseous basivertebral nerve ablation

ManufacturerRelievant Medsystems, Inc. (Intracept system components: RF probe, access instruments, RF generator)

Intended vertebral levelsIntended for ablation of basivertebral nerves of the L3 through S1 vertebrae

Policy Summary

PayerAmbetter Nevada

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document prior conservative therapy and response to diagnostic injections to support medical necessity.

SourceLink

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