CurrentCentenePolicy CP MP.170

Nerve Blocks and Neurolysis for Pain Management

Clinical coverage policy for invasive nerve block and neurolysis procedures for pain management in non-Medicare Centene-affiliated plans; describes indications, criteria, limits, and supporting clinical background for multiple nerve block types.

Policy Summary

PayerCentene

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP MP.170

Change TypeNo material changes

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for invasive nerve block/neurolysis procedures and document prior conservative therapy and response to diagnostic injections.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria for nerve blocks and neurolysis

Intercostal and Thoracic Regional Blocks

Intercostal and Thoracic Regional Blocks — Covered when ALL of the following are met:

ALL of the following

There is a suspected organic cause for the pain (e.g., post-herpetic neuralgia or other neuropathic thoracic process).
Pain and disability are of moderate to severe degree.
The member has not responded to an adequate trial of conservative modalities (e.g., NSAIDs, physical therapy, topical therapies, activity modification).
There is no evidence of contraindications such as local infection or pain that is predominantly psychogenic in origin.

Genicular Nerve Blocks, Neurolysis, and Radiofrequency Neurotomy

Genicular Nerve Procedures — Position and coverage summary

ALL of the following

Genicular nerve blocks, neurolysis, and radiofrequency neurotomy of articular genicular nerves have insufficient evidence to determine safety and effectiveness.
Requests for genicular nerve procedures are considered not medically necessary (insufficient evidence) unless new high-quality evidence emerges to support clinical benefit.

Intraosseous Radiofrequency Ablation of the Basivertebral Nerve (Intracept)

Basivertebral Nerve Ablation (Intracept) — Position and coverage summary

ALL of the following

There is insufficient evidence to determine the safety and effectiveness of intraosseous radiofrequency ablation of the basivertebral (Intracept) nerve for treatment of chronic low back pain.
Requests for basivertebral nerve ablation (Intracept) are considered not medically necessary (insufficient evidence) unless peer-reviewed evidence demonstrates clear clinical benefit and acceptable safety.

Required conservative therapy before interventional procedures

Documented trial and failure of conservative measures before therapeutic injections

Documented trial and failure of conservative measures before therapeutic injections — commonly 3 months for some indications or ≥3 weeks for CRPS

General conservative therapy requirement: Therapeutic injections generally require documented trial and failure of conservative therapies such as NSAIDs (unless contraindicated), activity modification, physical therapy/exercise, and appropriate oral medications (e.g., anticonvulsants, tricyclic antidepressants)Commonly 3 months for indications such as occipital therapeutic blocks

Documentation should include duration and response to prior conservative treatments

CRPS conservative therapy requirement: For CRPS, failure of at least 3 weeks of conservative therapies (e.g., activity modification, exercises, topical agents, oral medical management) is required prior to sympathetic nerve block consideration>= 3 weeks

Care should be managed by a specialist experienced in CRPS

Limits on procedure frequency and repeat intervals

inv-48: Occipital nerve block (includes diagnostic) — no more than four injections

LimitNo more than four occipital nerve injections (including diagnostic) within any 12‑month period

IndicationTherapeutic occipital blocks require prior temporary relief from a diagnostic injection and failure of 3 months of conservative therapy (NSAIDs, activity modification, oral anticonvulsants or tricyclics)

Not coveredOccipital nerve block for migraine or cervicogenic headache is considered not medically necessary

inv-49: Additional sympathetic or peripheral therapeutic injections — at least one week between injections

Minimum intervalAdditional sympathetic or peripheral therapeutic injections must be given at least 1 week apart

CRPS requirement

Procedure and billing codes

Coding notemixed

No codes listed

Covered CPT Codes (partial list)CPT

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

Neurolytic and additional CPT CodesCPT

64454	Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
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
64624	Destruction by neurolytic agent; genicular nerve branches including imaging guidance, when performed

1–10 of 14

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inv-19: Occipital injection frequency coding note — ≤4 injections/12 months

Coding limitOccipital injections coded/limited to ≤4 injections per 12 months (this includes diagnostic injections)

Inclusion noteThis coding threshold applies to both diagnostic and therapeutic occipital injections as stated in policy

Prior authorizationPrior authorization required for invasive nerve block procedures for non‑Medicare Centene plans (one procedure per visit policy applies)

inv-20: Inter-injection spacing coding note — repeat interval ≥1 week

Minimum spacingInter‑injection spacing requirement: repeat therapeutic sympathetic or peripheral injections must be ≥1 week apart

Prior authorization, documentation, and provider responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for invasive nerve block and neurolysis procedures for non‑Medicare Centene plans. Only one invasive nerve block or neurolytic procedure is authorized per visit unless the request documents medical necessity for additional simultaneous procedures. When a peripheral or ganglion nerve block is performed as part of another surgical or interventional procedure and is billed as integral to that procedure, separate prior authorization and separate payment may not be required — follow proper coding practices and the other procedure’s authorization guidance.

One invasive nerve block/neurolysis procedure authorized per visit unless medical necessity for additional procedures is documented
If block is performed as part of another procedure, it may not require separate authorization — follow coding and the primary procedure’s authorization rules

Documentation Required

Post‑herniorrhaphy Evaluation and Documentation

For post‑herniorrhaphy (post‑inguinal hernia repair) neuralgia, document that pain has persisted at least three months after surgical repair and that imaging has been performed to exclude non‑neuropathic causes. Initial diagnostic peripheral nerve block must show temporary relief. Therapeutic blocks may be repeated at intervals of 1–3 weeks when there is documented clinical benefit.

Imaging and procedural monitoring guidance

Note

Imaging optional for general nerve block procedures

General nerve block procedures may be performed with or without radiographic guidance; imaging is optional and should be used based on clinical indication and coding practices.

Procedures may be performed with or without imaging guidance
If part of surgery, coding may follow operative coding practices and not be authorized separately

Note

Radiologic monitoring as clinically indicated for certain procedures

Intercostal blocks, celiac plexus neurolysis, and intraosseous basivertebral ablation may require radiologic monitoring or imaging as clinically indicated; some neurolytic procedures specify radiologic monitoring.

Ultrasound guidance can reduce pneumothorax risk for intercostal blocks
Celiac plexus and some neurolytic procedures may require radiologic monitoring

Clinical background and evidence summary

Nerve blocks produce a temporary interruption of peripheral nerve conduction by injection of local anesthetic (with or without adjuncts) and can serve a diagnostic role (for example confirming nerve-mediated pain when a block produces temporary relief) or a therapeutic role when diagnostic response plus prior conservative therapy failure support repeat treatment. The policy differentiates blocks by anatomic target and evidence base: occipital blocks are emphasized as a diagnostic test for occipital neuralgia and only supported therapeutically after documented benefit from a diagnostic injection and failed conservative care, while other blocks (e.g., celiac plexus neurolysis) have stronger evidence for selected indications.

Key definitions and device descriptions

inv-37: Occipital neuralgia definition — posterior scalp paroxysmal pain description

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

Associated featuresMay be accompanied by diminished sensation or dysesthesia and tenderness over the involved nerves

Diagnostic roleRelief after a local anesthetic block of the affected nerve is included in IHS diagnostic criteria

inv-38: Sympathetic nerve block utility definition — diagnostic and therapeutic uses (e.g., CRPS)

Primary usesSympathetic nerve blocks are used diagnostically to identify sympathetic contribution to pain, therapeutically for conditions responsive to sympathetic blockade (e.g., CRPS), and prognostically to predict outcomes of longer‑term interventions

Procedures considered not medically necessary or not covered

The policy lists multiple procedures and indications that are considered not covered or insufficiently supported. Examples specifically named as not medically necessary include occipital nerve block for migraine or cervicogenic headache and sympathetic nerve blocks for ischemic limb pain and other non‑CRPS indications. It also identifies procedures with insufficient evidence such as genicular nerve procedures and intraosseous basivertebral nerve ablation (Intracept), and states that peripheral nerve blocks for trigeminal neuralgia have insufficient evidence to support use. Inclusion of a procedure code in the policy does not imply coverage; clinical criteria and member benefit terms must be met.

Occipital nerve block for migraine/cervicogenic headache is considered not medically necessary due to lack of established effectiveness; sympathetic nerve blocks for non‑CRPS indications (including ischemic limb pain) are not covered. Peripheral nerve blocks for trigeminal neuralgia are unsupported by sufficient evidence and thus not covered as standard therapy.

Genicular nerve blocks and radiofrequency neurotomy, as well as intraosseous basivertebral nerve ablation, are identified as having insufficient evidence to determine safety and effectiveness; these interventions are therefore not established as covered therapies under this policy.

Sympathetic blocks are limited to CRPS when criteria are met; when used for other indications the evidence does not support coverage. Providers should document objective findings and response to initial blocks to justify additional treatment when appropriate.

If peripheral or occipital blocks are being requested for headache management, documentation must show why standard, evidence-based migraine or cervicogenic therapies are inadequate; absent such evidence these uses are considered not medically necessary.

Failure of ≥6 months conservative care

Basivertebral ablation conservative care requirement: Basivertebral nerve ablation (Intracept) eligibility requires failure of at least 6 months of conservative care prior to the procedure>= 6 months

Conservative care duration must be documented

Refractory to conservative therapy

Refractory to conservative therapy: (See specific procedure criteria for required conservative therapy trials and documentation)

This node is a placeholder; apply the conservative requirements specified under each procedure

Standards of Practice and Evidence Consideration

Providers must consider standards of medical practice and available evidence; conservative therapy requirements not fully specified here

Provider responsibility: Providers should use professional medical judgment, follow current standards of medical practice, and consider available evidence and applicable coverage rules (including state/Medicare NCDs/LCDs) when evaluating conservative therapy requirements and indications for interventional procedures

Coverage decisions remain subject to terms, conditions, exclusions, and limitations of the member's coverage documents

inv-50: Celiac plexus block repeat — at least three months since previous injection for chronic pancreatitis

Repeat intervalRepeat celiac plexus block for chronic pancreatitis is allowed only when at least 3 months have passed since the previous injection

Clinical benefit requirementRepeat block requires evidence of clinical benefit from the initial celiac block (pain alleviation or reduced analgesic need)

LimitationsRepeat celiac plexus procedures for indications other than specified are not medically necessary

inv-51: Celiac plexus neurolysis — repeat effectiveness ~30%; repeat not routinely recommended

Effectiveness on repeatRepeat celiac plexus neurolysis is effective in only about 30% of cases and is not routinely recommended

EvidenceCochrane and meta-analytic data show pooled relief for pancreatic cancer patients of 53–80% after celiac plexus neurolysis

TimingOptimal timing is uncertain; neurolysis may reduce opioid use but effects diminish over time

inv-52: Post-herniorrhaphy nerve blocks — positive responders may be treated every 1–3 weeks until relief sustained

Post-op respondersPatients with positive response to an initial post‑herniorrhaphy nerve block may be treated every 1–3 weeks until sustained relief is achieved

EvaluationPersistent post‑herniorrhaphy pain should prompt imaging to exclude non‑neuropathic causes before repeat blocks

EscalationIf pain recurs after initial benefit, percutaneous nerve ablation or surgical neurectomy may be considered

inv-53: Not specified in this part — placeholder for unspecified frequency limits

Unspecified limitsNo additional frequency limits are specified in this section of the policy

Coverage caveatCoverage decisions remain subject to the member's coverage documents and applicable state/Medicare rules

Provider responsibilityProviders should verify prior authorization and documentation requirements with the Health Plan

inv-21: Celiac plexus repeat interval coding note — retrial ≥3 months

Required intervalCeliac plexus repeat interval for chronic pancreatitis: at least 3 months since prior injection

Benefit documentationRepeat permitted only when there was clinical benefit from the initial block (pain relief or reduced analgesic need)

Other indicationsRepeat celiac plexus procedures for indications not specified are considered not medically necessary

inv-22: Conservative care duration for basivertebral nerve ablation — >= 6 months

Conservative care durationBasivertebral (Intracept) nerve ablation is intended for patients who have not responded to at least 6 months of conservative care

Imaging requirementEligible patients should have Modic type 1 or 2 changes on MRI consistent with vertebrogenic pain

Evidence qualityExisting studies report pain and function improvement but are limited in size and quality; long‑term independent trials needed

Documentation Required

Conservative Therapy Prerequisites

Conservative therapy must be attempted and documented before some diagnostic and all therapeutic nerve blocks, as specified in the policy. Examples include activity modification, heat/rest, physical therapy (including massage), and appropriate pharmacologic therapy (e.g., NSAIDs unless contraindicated, oral anticonvulsants or tricyclic antidepressants). Document duration and response to each conservative treatment.

Documented trial of at least 3 months of conservative treatments when required (e.g., for occipital neuralgia therapeutic blocks)
List conservative measures tried with dates, dosing (when applicable), and clinical response
Note contraindications or intolerance to specific therapies when applicable

Documentation Required

Conservative Care and Timing Considerations for Celiac Plexus Neurolysis

Celiac plexus nerve block or neurolysis should be reserved for patients with pancreatic cancer‑related pain or refractory chronic pancreatitis after failure of conservative management. Document the indication (pancreatic cancer with severe visceral abdominal/back pain or chronic pancreatitis with non‑dilated pancreatic duct), prior opioid usage/limitations, and that conservative measures have been inadequate. Consider timing: benefits may be greater earlier in pancreatic cancer but effects can diminish over time; repeat neurolysis for pancreatic cancer is generally not routinely recommended because of limited effectiveness.

Indications: pancreatic cancer with severe visceral abdominal/back pain or refractory chronic pancreatitis with non‑dilated duct
Document prior conservative management and opioid therapy status/side effects
If repeat celiac plexus neurolysis is requested, document prior clinical benefit from the initial block; repeat procedures for pancreatic cancer have limited effectiveness and are used selectively

Documentation Required

Provider Responsibilities and Required Clinical Documentation

Ensure the record includes diagnosis, pain characteristics, prior treatments and their durations/responses, and specialist review when applicable. Providers retain responsibility for clinical decisions and should verify prior authorization status, applicable NCDs/LCDs, and state/Medicare rules. Coding inclusion in this policy does not guarantee coverage — confirm current coding guidance before claim submission.

Document: diagnosis, pain distribution/quality/severity, prior injections and objective response, conservative therapies tried with dates and outcomes
Verify prior authorization and applicable Medicare/local coverage determinations where relevant
Inclusion of codes in the policy is informational only — verify up‑to‑date coding guidance prior to billing

Note

Procedure‑dependent imaging (ultrasound or endoscopic ultrasound)

Imaging guidance for genicular nerve blocks and celiac plexus interventions is procedure‑dependent; techniques referenced include ultrasound and endoscopic ultrasound in the supporting literature.

Genicular procedures: imaging guidance (e.g., ultrasound) as indicated
Celiac plexus interventions: endoscopic ultrasound guidance referenced in literature

inv-39: Intracept Intraosseous Nerve Ablation System — FDA-approved basivertebral nerve ablation (L3-S1)

DeviceIntracept Intraosseous Nerve Ablation System is FDA‑cleared for thermal ablation of basivertebral nerves of L3 through S1

IndicationIntended to relieve chronic low back pain of at least 6 months' duration not responsive to ≥6 months conservative care and with Modic type 1 or 2 MRI findings

EvidenceRandomized sham‑controlled trials report pain and function improvement, but most studies are company‑sponsored and limited in size/quality

inv-40: Genicular nerve procedures definition — blocks/neurolysis/RF for knee joint sensory nerves; evidence limited

DefinitionGenicular nerve procedures encompass blocks, neurolysis, and radiofrequency neurotomy targeting sensory nerves around the knee joint

EvidenceThe evidence is limited and conflicting; small studies suggest possible benefit but high‑quality data are insufficient

GuidanceHayes assessments and additional trials are referenced; further research needed to establish safety and efficacy

inv-41: Genicular nerve procedures — additional references to Hayes assessments and evidence notes

Evidence resourcesGenicular nerve procedures are discussed in Hayes health technology assessments and randomized trials cited in the policy references

Clinical statusProcedures are emerging options for knee osteoarthritis pain but current evidence is insufficient and sometimes conflicting

RecommendationFurther high‑quality research is needed to define safety and effectiveness

inv-42: Celiac plexus neurolysis definition — endoscopic or percutaneous neurolytic interventions with Cochrane/RCT support for pancreatic cancer

DefinitionCeliac plexus neurolysis refers to endoscopic or percutaneous neurolytic interventions targeting the celiac plexus for pancreatic cancer or other pancreatic pain

Evidence baseSupported by Cochrane review and RCTs showing reduced opioid use and pooled pain relief (53–80%) in pancreatic cancer

Clinical noteOptimal timing is uncertain; neurolysis effects diminish over time and repeat neurolysis is only ~30% effective

inv-43: Intraosseous basivertebral nerve ablation — ablation for vertebrogenic low back pain with RCT and FDA references

ProcedureIntraosseous basivertebral nerve ablation is thermal ablation of the basivertebral nerve for vertebrogenic low back pain

Indication criteriaIntended for chronic low back pain ≥6 months, refractory to ≥6 months conservative care, and with Modic type 1 or 2 MRI changes

Regulatory and trial supportRCTs and FDA 510(k) documentation are cited; existing trials are limited and often industry‑sponsored

The policy specifically notes that there is insufficient evidence in the peer-reviewed literature to support the use of peripheral nerve blocks for treatment of trigeminal neuralgia. Initial therapy should be pharmacologic, and surgical options may be discussed for refractory cases.