CurrentCentenePolicy CP MP.170

Nerve Blocks and Neurolysis for Pain Management

Policy governs medical necessity criteria for invasive nerve block and neurolytic procedures (diagnostic and therapeutic) for various indications including occipital neuralgia, sympathetic blocks for CRPS, celiac plexus blocks/neurolysis for pancreatic cancer and chronic pancreatitis, intercostal nerve blocks, genicular nerve procedures, peripheral/ganglion nerve blocks (including post-herniorrhaphy neuralgia), and intraosseous basivertebral nerve ablation. Applies to non-Medicare Centene-affiliated health plans; notes cross-references for Medicare and other related policies.

Policy Summary

PayerCentene

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP MP.170

Change TypeAnnual review (clarifying edits); prior substantive revisions noted

Effective DateFeb 1, 2025

Next Review Date

Key ActionDocument required prior response and conservative therapy before approving therapeutic occipital blocks (temporary relief from prior injection and failure of three months of conservative treatment).

POLICY UPDATE CHANGES

Annual review. Added note in Description to refer to CP.MP.171 Facet Joint Interventions and Medicare cross-reference; clarifying verbiage regarding non‑Medicare health plans with no impact to criteria; update made in Criteria VLB.2.b. for clarity.

Added CPT code 64628 and minor rewording with no clinical significance in 08/23 and subsequent reviews.

8Major Sections with Criteria

4Max occipital injections/12 months

Sympathetic block temp improvement threshold

60+Literature/Guidance references

Coverage Summary

Policy Number CP MP.170 (Clinical Policy: Nerve Blocks and Neurolysis for Pain Management) governs medical necessity criteria for invasive nerve block and neurolytic procedures — diagnostic and therapeutic — for multiple indications. Payer: Centene (non‑Medicare affiliated health plans). Effective date: 2025-02-01.

Scope includes occipital neuralgia (diagnostic and therapeutic occipital nerve blocks), sympathetic nerve blocks for complex regional pain syndrome (CRPS), celiac plexus nerve block/neurolysis for pancreatic cancer and refractory chronic pancreatitis (non‑dilated duct), intercostal nerve block/neurolysis for chronic neuralgia (e.g., post‑herpetic), genicular nerve procedures, peripheral/ganglion nerve blocks (including post‑herniorrhaphy neuralgia and malignant pain management), and intraosseous basivertebral (BVN) radiofrequency ablation. Applies to non‑Medicare Centene‑affiliated plans; Medicare members should also refer to applicable Medicare NCDs/LCDs (see cross‑references).

Coverage stance overview: mixed — several indications are covered when specific criteria are met (e.g., occipital blocks with diagnostic/therapeutic criteria; sympathetic blocks for CRPS with defined diagnostic findings and rehab/management requirements; celiac plexus neurolysis for pancreatic cancer and selected chronic pancreatitis cases; intercostal blocks for chronic neuropathic intercostal pain; peripheral blocks for malignant pain and post‑herniorrhaphy neuralgia). Other indications lack sufficient evidence or are considered not medically necessary (e.g., sympathetic blocks for ischemic limb pain, peripheral nerve blocks for headaches/trigeminal neuralgia, genicular procedures have insufficient evidence, intraosseous BVN ablation has insufficient evidence per this policy).

Medicare cross‑references and guidance: policy notes to review Medicare references including MC.CP MP.170 and specific LCDs (e.g., L39420 for BVN ablation and L36850/L33933/A57788 for peripheral nerve blocks) when treating Medicare members; state Medicaid provisions take precedence for Medicaid members.

Thresholds

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

Sympathetic block repeat intervalNerve blocks are given at least one week apart

Sympathetic block positive responseImmediate positive response defined as improved temperature of ≥ 1.5°C and decreased pain

Celiac plexus repeat intervalAt least three months since previous injection for refractory chronic pancreatitis with non-dilated duct

Post-herniorrhaphy persistence thresholdGroin pain has persisted for three months after surgical hernia repair

Medical Necessity Criteria (by indication)

Occipital Nerve Block - Not Medically Necessary

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

Celiac Plexus - Not Medically Necessary

Repeat celiac plexus nerve blocks or neurolysis, for any indication other than pancreatic cancer or refractory chronic pancreatitis with non-dilated duct, are not medically necessary

Intercostal Nerve Block/Neurolysis

Intercostal nerve block/neurolysis is medically necessary for chronic neuralgia due to post-herpetic neuralgia or other neuropathic process when ALL of the following are met:

Coding

Referenced CPT codes (informational)CPT

64400	Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (i.e., 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

1–10 of 26

1/3

Referenced Local Coverage Determinationsmixed

L39420	LCD: thermal destruction of the intraosseous basivertebral nerve (BVN) for vertebrogenic lower back
L36850	LCD: peripheral nerve blocks
L33933	LCD: peripheral nerve blocks
A57788	Local coverage article: peripheral nerve blocks

Referenced FDA Device Clearancemixed

510(k)

FDA 510(k) Premarket Notification: Intracept Intraosseous Nerve Ablation System (RF Probe), Intracept Access Instruments, Relievant RF Generator (03/2019)

Provider Actions & Billing Rules

Documentation Required

Occipital block documentation of prior response and conservative therapy

For therapeutic occipital nerve blocks (CPT 64405) document temporary relief from the prior/initial injection (e.g., reduction in numeric pain rating reported by the patient) and failure of at least three months of conservative therapy including heat/rest/physical therapy (including massage), NSAIDs unless contraindicated or not tolerated, oral anticonvulsants or tricyclic antidepressants, and activity modification to address triggers.

Affected code: 64405
Document prior temporary relief (reduction in reported pain score)
Document three months of conservative therapies (heat/rest/therapy, NSAIDs, anticonvulsant or TCA, activity modification)

Prior Authorization

Limit on number of injections

Background & Evidence Summary

Background summary: This policy provides clinical background and evidence context for occipital, sympathetic, celiac plexus, intercostal, genicular, peripheral/ganglion nerve blocks and intraosseous basivertebral nerve (BVN) ablation.

Occipital blocks: Greater occipital nerve blocks are used primarily as a diagnostic test for occipital neuralgia and may be used therapeutically for chronic occipital neuralgia; effectiveness in primary headache syndromes is controversial. The International Headache Society (IHS) defines occipital neuralgia consistent with the diagnostic criteria referenced in this policy.

Sympathetic blocks: Sympathetic blockade is diagnostic and therapeutic for CRPS; the response to sympathetic blockade is the best diagnostic test for CRPS. Evidence for sympathetic blocks is limited and use for other indications (e.g., ischemic limb pain) is not supported.

Celiac plexus nerve block/neurolysis: Recommended and medically necessary for pancreatic cancer with severe visceral pain when opioids are ineffective or intolerable and no somatic malignancy is present; supported by guideline recommendations and a 2011 Cochrane review showing reduced opioid use and lower pain. For chronic pancreatitis with a non‑dilated duct, celiac plexus blockade is an option for refractory pain (ACG conditional recommendation, very low quality evidence); benefit is often transient (months) and repeat injections require evidence of prior benefit and timing criteria.

Intercostal nerve blocks: Used for chest/upper abdominal pain such as post‑herpetic neuralgia or rib fractures; may be performed with ultrasound guidance to reduce complications. Indicated when there is a suspected organic cause, nonresponse to conservative measures, and moderate to severe pain/disability.

Genicular procedures: The genicular nerve interventions (blocks, neurolysis, radiofrequency neurotomy) are emerging for knee pain/osteoarthritis; current evidence is limited and conflicting — insufficient to determine safety and effectiveness.

Peripheral/ganglion nerve blocks: Appropriate as part of comprehensive management for malignant pain and for diagnostic/therapeutic management of post‑herniorrhaphy neuralgia when specific criteria are met; limited evidence supports use for migraine prevention/treatment in pregnancy and trigeminal neuralgia.

Medicare Determinations & References

Name	Number	Effective Date	Type
Medicare reference
MC.CP MP.170

other
Thermal destruction of the intraosseous basivertebral nerve (BVN) for vertebrogenic lower back pain
L39420
2023-03-05
LCD
Peripheral nerve blocks
L36850
2017-01-01
LCD
Peripheral nerve blocks
L33933
2015-01-01
LCD
Peripheral nerve blocks
A57788
2018-01-01
Local Coverage Article

Definitions

Definitions:

CRPS — Complex regional pain syndrome (also called reflex sympathetic dystrophy).

Therapeutic block — Injection intended to treat pain with expectation of symptom relief (often following a diagnostic block).

Diagnostic block — Injection intended to identify the source of pain or predict response to more definitive interventions.

Revision History

08/18material change

Policy split from CP MP.118 and expanded sections including criteria for sympathetic nerve block for CRPS and celiac plexus neurolysis for pancreatic cancer; changed ischemic leg indication to not medically necessary; added requirement of positive response to first/second sympathetic block and that additional blocks be at least one week apart. (Revision Date = 08/18; Approval Date = 08/18)

08/23non-material revision

Annual review with minor rewording and addition of CPT code 64628; background updated. (Revision Date = 08/23; Approval Date = 08/23)

02/25non-material revisionLatest

Policy Summary

PayerCentene

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP MP.170

Change TypeAnnual review (clarifying edits); prior substantive revisions noted

Effective DateFeb 1, 2025

Next Review Date

On This Page

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Genicular Nerve Blocks/Neurolysis/Radiofrequency Neurotomy

Coverage stance:

There is insufficient evidence to determine safety and effectiveness of genicular nerve blocks, neurolysis and radiofrequency neurotomy of the articular nerve

Peripheral/Ganglion Nerve Blocks - Malignant Pain

Peripheral nerve blocks for diagnosis and treatment of malignant pain:

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

Peripheral Nerve Blocks - Post-Herniorrhaphy Neuralgia (Diagnostic and Therapeutic)

Peripheral nerve blocks for diagnosis or treatment of post-herniorrhaphy pain are medically necessary when ALL of the following are met:

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Intraosseous Radiofrequency Ablation of Basivertebral Nerve

Coverage stance:

There is insufficient evidence to determine the safety and effectiveness of intraosseous radiofrequency nerve ablation of the basivertebral nerve for treatment of chronic low back pain

No more than four occipital injections (includes diagnostic injection) are allowed within any 12-month period. Repeated injections may require documentation of benefit. This limit applies to injections billed with the listed codes and related neurolytic/genicular codes as applicable.

Affected codes: 64405, 64624
Threshold: No more than four injections in a 12‑month period (includes diagnostic injection)

Documentation Required

Sympathetic block repeat criteria

For additional sympathetic nerve blocks for CRPS (codes include CPT 64510 and 64520) document that the first or second block produced an immediate positive response (improved temperature of ≥ 1.5°C and decreased pain) and that repeat blocks are administered at least one week apart.

Affected codes: 64510, 64520
Requirements: Immediate positive response to prior block (temperature improvement ≥ 1.5°C plus decreased pain)
Timing: Blocks given at least one week apart

Documentation Required

Celiac plexus benefit for repeat block

Repeat celiac plexus injections/neurolysis (e.g., CPT 64530 or 64680) for refractory chronic pancreatitis require documentation that at least three months have passed since the previous injection and that the initial celiac block produced clinical benefit (alleviation or reduction of abdominal pain or elimination of the need for oral analgesia).

Affected codes: 64530, 64680
Requirements: ≥ 3 months since prior injection and documented clinical benefit from the prior celiac block (pain reduction or decreased need for oral analgesics)

Billing Rule

Peripheral/ganglion nerve blocks during other procedures

When peripheral or ganglion nerve blocks are administered as part of a surgery or other procedure, coding should follow proper coding practices; such blocks may be billed as part of that procedure and are not necessarily subject to separate authorization or separate payment.

Peripheral/ganglion nerve blocks given during another medically necessary procedure may be included in that procedure's billing
Separate authorization or payment may not be required when appropriately coded as part of the primary procedure

Documentation Required

Reference applicable NCDs/LCDs and plan criteria

Providers must review and apply all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles when treating Medicare members. For Medicaid members, state Medicaid provisions take precedence over this policy.

Reference Medicare determinations (NCDs/LCDs) and Local Coverage Articles as applicable
For Medicaid members, apply state Medicaid coverage provisions where they conflict with this policy

Intraosseous BVN ablation: Basivertebral nerve radiofrequency ablation (e.g., Intracept) has FDA 510(k) clearance but available clinical studies are mostly small, company‑sponsored, and of limited quality; current evidence is insufficient to determine safety and effectiveness and policy states insufficient evidence for routine coverage.

Evidence Item	Finding/Value
Celiac pooled rates
53% to 80% (meta-analysis/systematic review)
Cochrane
Significantly reduced opiate use and lowered pain compared to control (2011 Cochrane review)
Intraosseous basivertebral ablation
Evidence limited; mostly company-sponsored small studies; insufficient to conclude safety/effectiveness
Key RCTs and studies referenced
Multiple randomized controlled trials and systematic reviews cited for basivertebral nerve ablation, occipital nerve blocks, peripheral blocks, and radiofrequency ablation
Hayes assessment
Radiofrequency nerve ablation for knee OA HTA (Published Dec 22, 2020; reviewed Dec 28, 2023)

Annual review; added note in Description to refer to CP.MP.171 Facet Joint Interventions and Medicare cross-reference MC.CP MP.170; clarifying verbiage regarding non‑Medicare health plans with no impact to criteria; update made in Criteria VLB.2.b. for clarity. (Revision Date = 02/25; Approval Date = 02/25)