Currentcare_continuumPolicy n05698

Nerve Blocks and Ablation Therapy for the Treatment of Pain

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Defines medical necessity criteria and exclusions for peripheral nerve blocks and ablation therapies for treatment of acute and chronic pain for Network Health Plan members, including guidance for Medicare Advantage when CMS NCD/LCD are absent.

Policy Summary

Payercare_continuum

PolicyNerve Blocks and Ablation Therapy for the Treatment of Pain

Policy CodePolicy n05698

Change TypeNo material change

Effective DateMar 1, 2021

Last ReviewJun 18, 2026

Next Review DateJun 18, 2027

Key ActionFollow Medicare NCD/LCD for Medicare Advantage members and apply internal medical necessity criteria and prior authorization where CMS guidance is absent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8 codesRelated procedure codes

follows CMSMedicare Advantage alignment

investigationalAblation stance

multiple sitesConditions referenced

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Currentcare_continuumPolicy n05698

Nerve Blocks and Ablation Therapy for the Treatment of Pain

Customize your policy alerts

Sign up for care_continuum Policy n05698 alerts

Get alerted when Policy n05698 changes without checking for updates manually.

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Policy Summary

Payercare_continuum

PolicyNerve Blocks and Ablation Therapy for the Treatment of Pain

Policy CodePolicy n05698

Change TypeNo material change

Effective DateMar 1, 2021

Last ReviewJun 18, 2026

Next Review DateJun 18, 2027

Key ActionFollow Medicare NCD/LCD for Medicare Advantage members and apply internal medical necessity criteria and prior authorization where CMS guidance is absent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8 codesRelated procedure codes

follows CMSMedicare Advantage alignment

investigationalAblation stance

multiple sitesConditions referenced

Coverage Criteria

Covered Indications

Covered when ALL of the following apply for regional or peripheral blocks:

Regional/local block for anesthesia with surgery: Regional or local block administered for anesthesia in conjunction with surgery (administered the same day as the surgery) is considered reasonable and necessary.

[[chunk 4]]

Peripheral nerve block for diagnostic purposes: Peripheral nerve block administered for diagnostic purposes when the clinical picture is unclear may be considered reasonable and necessary.

[[chunk 4]]

Ablation / Experimental Review

Ablation therapy for pain: The use of ablation therapy to treat pain for all indications will be reviewed under Network Health's experimental, investigational, and/or unproven process.

Includes but is not limited to cryoablation/cryoneurolysis (e.g., Iovera), rhizotomy, laser, electrical, chemical, or radiofrequency ablation [[chunk 4]]

The policy classifies the use of ablation therapy for treatment of pain as subject to the plan's experimental, investigational, and/or unproven review process. As stated in the policy, this review applies to all indications and to multiple ablative modalities, including but not limited to chemical, thermal, radiofrequency, cryotherapy (cryoablation/cryoneurolysis), rhizotomy, laser, and electrical techniques. Prior authorization and coverage determinations for such services will follow the plan’s investigational review procedures rather than standard medical necessity criteria.

Because ablation techniques aim to destroy nerve tissue to prevent transmission of pain signals, the policy does not routinely consider these procedures medically necessary for pain management. The document explicitly notes that ablation therapy to treat pain for all indications will be reviewed under Network Health's experimental, investigational, and/or unproven process, meaning these therapies are not routinely covered and will require case-by-case review under the plan’s investigational policy.

Conservative Treatment Requirements

Coding and Billing

Related CPT/HCPCS Codesmixed

0440T	Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441T	Ablation, percutaneous cryoablation, includes imaging guidance, lower extremity distal/peripheral nerve
0442T	Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (e.g., brachial plexus, pudendal nerve)
C9808	Nerve cryoablation probe (e.g. cryoICE, cryoSPHERE, cryoSPHERE MAX, cryo2) including probe and all disposable system components
C9809	Cryoablation needle (e.g. Iovera system), including needle/tip and all disposable system components
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve
64450	Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch
64640	Destruction by neurolytic agent, other peripheral nerve or branch

CPT list currency

CPT codes subject to changeCPT codes listed in this policy (e.g., 0440T, 0441T, 0442T, C9808, C9809, 64405, 64450, 64640) may be retired or revised over time; verify current CPT/HCPCS coding before billing.

Verify against payer and CMS guidanceNetwork Health follows Medicare NCDs/LCDs for Medicare Advantage; where absent, internal policy applies — confirm applicable coding with payer-specific guidance.

Code descriptions are provided for referencePolicy includes code descriptions (e.g., 0440T = percutaneous cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve).

Include supply/device codes when applicableCodes for disposable system components (e.g., C9808, C9809) are listed and should be billed per payer rules when supplies are used.

Imaging Requirements

Prior Authorization

Coverage determination and prior authorization guidance

Network Health follows Medicare NCD/LCD when applicable for Medicare Advantage members; where CMS coverage is absent, prior authorization decisions will follow the plan's internal medical necessity criteria and contractual benefit documents.

Prior authorization is required and will be adjudicated based on applicable NCD/LCD or the policy's medical necessity criteria.
Providers must submit documentation supporting the indication and clinical rationale per the plan's utilization management requirements.

Provider Actions and Prior Authorization

Prior Authorization

Prior authorization follows Medicare NCD/LCD when applicable; otherwise use internal criteria

Follow Medicare NCDs/LCDs for Medicare Advantage members when available; when no applicable Medicare determination exists, prior authorization and medical necessity determinations will be based on this internal policy and contractual benefit documents.

Prior authorization decisions will follow CMS NCD/LCD for Medicare Advantage when those coverage determinations exist.
If no Medicare NCD/LCD applies, use the internal policy criteria and the member’s contractual benefit documents to determine prior authorization requirements.

Note

Verify contractual and CMS utilization management requirements before proceeding

Follow contractual benefit documents and CMS statements; verify coverage specifics and any utilization management requirements before scheduling procedures.

Confirm applicable utilization management or medical director review requirements per the member’s plan documents.
For Medicare members, ensure applicable CMS coverage statements (NCD/LCD) are applied.

Definitions

Peripheral nerve block definition

DefinitionA regional or local injection administered to temporarily disrupt transmission of pain for diagnostic or therapeutic purposes; diagnostic blocks are used to isolate the pain source when the clinical picture is unclear, and therapeutic blocks treat a known pain source.

Purpose - DiagnosticDiagnostic peripheral nerve block is used to isolate the cause of pain when the cause is unclear; if the cause is already known, the block is not considered diagnostic.

Purpose - TherapeuticTherapeutic peripheral nerve block is used to treat pain when the pain source is already known.

Ablation therapy definition

DefinitionDestruction of nerves by chemical, thermal, radiofrequency, cryotherapy, or other modalities to reduce acute or chronic pain by preventing transmission of pain signals.

Modalities included

Background

Peripheral nerve blocks are described as injections intended to temporarily disrupt pain transmission and may be used for either diagnostic or therapeutic purposes. A diagnostic block is used to localize the pain generator when the clinical picture is unclear; once the pain source is known the block is no longer considered diagnostic. A therapeutic block is performed to treat a known pain source. These distinctions guide when regional or peripheral nerve blocks may be considered reasonable and necessary under the plan’s coverage criteria.

Not Covered / Experimental

NOT COVERED: The policy treats ablation therapy for pain as experimental/investigational for all indications. This includes, but is not limited to, cryoablation/cryoneurolysis (e.g., Iovera), rhizotomy, laser, electrical, chemical, and radiofrequency ablation. Coverage determination for any such procedure will proceed through Network Health’s experimental/unproven review process and is not routinely approved under standard medical necessity criteria.