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CurrentCentenePolicy CP.MP.170

Clinical Policy: Nerve Blocks and Neurolysis for Pain Management

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Medical necessity and coverage criteria for various peripheral and sympathetic nerve blocks, celiac plexus interventions, intercostal and peripheral/ganglion blocks, and related procedures for non-Medicare Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDocument diagnostic response and prior conservative therapy when requesting prior authorization for invasive pain procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤4/12 mooccipital limit

≥3 moconservative occipital

≥1 weeksympathetic interval

≥3 monthsrepeat celiac interval

~30%repeat celiac effectiveness

Coverage Criteria for Nerve Blocks and Neurolysis

Occipital Nerve Block

Covered when ALL of the following are met

Occipital diagnostic injection: Patient has unilateral or bilateral pain in the distribution of the greater, lesser and/or third occipital nerves AND pain has at least two characteristics: recurring paroxysmal attacks, severe intensity, or shooting/stabbing/sharp quality AND pain is associated with dysesthesia and/or allodynia on innocuous stimulation of the scalp/hair with at least one finding: tenderness over affected nerve branches or trigger point at nerve emergence

Initial injection for diagnosis

Therapeutic occipital block: There was temporary relief from the initial/previous injection as evidenced by a reduction in numeric rating scale pain score AND the member/enrollee has failed three months of conservative treatment including heat/rest/physical therapy (including massage), NSAIDs unless contraindicated, oral anticonvulsants or tricyclic antidepressants, and activity modification AND no more than four injections are given within 12 months (includes diagnostic injection)<=4 injections/12 months

Therapeutic criteria

Policy Summary

PayerCentene

PolicyNerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDocument diagnostic response and prior conservative therapy when requesting prior authorization for invasive pain procedures.

SourceLink

On This Page

Extracted clinical coverage concepts

Selected coverage-relevant clinical statements present in this section:

Celiac plexus neurolysis for pancreatic cancer: EUS-guided celiac plexus neurolysis demonstrates pooled pain relief in 53–80% of treated pancreatic cancer patients and reduces opioid use; optimal timing is uncertain and repeat neurolysis is effective only ~30% and is not recommended

Supports selective coverage; repeat not routinely recommended

Celiac plexus block for chronic pancreatitis: Celiac plexus blockade can be considered for refractory pain in chronic pancreatitis with a non-dilated duct; relief typically lasts 3–6 months and guideline support is conditional (very low quality)

Supports consideration after conservative measures

Genicular nerve procedures status: Genicular nerve blocks and radiofrequency neurotomy are emerging with limited and conflicting evidence; small studies suggest possible benefit but further research is needed

Emerging / investigational

Basivertebral nerve ablation (Intracept) context: Intracept is FDA-cleared for L3–S1 basivertebral nerve ablation for chronic low back pain with ≥6 months of symptoms and ≥6 months of conservative care plus Modic type 1 or 2 MRI findings, but published evidence is limited and guideline support is weak/conflicted>= 6 months conservative care; Modic type 1 or 2 MRI features

Suggests restrictive coverage with imaging and conservative therapy prerequisites

Coding and Regulatory References

Referenced CPT CodesCPT

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.

1–10 of 30

1/3

Regulatory / Device codes referencedmixed

510(k)

FDA premarket notification referenced for Intracept Intraosseous Nerve Ablation System

CMS LCD / LCA referencesmixed

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

inv-17: Conservative care duration prior to basivertebral nerve ablation — >= 6 months

Required conservative care duration>= 6 months of documented conservative therapy prior to basivertebral (Intracept) ablation

Imaging prerequisiteMRI evidence of Modic type 1 or 2 changes on affected vertebral endplates

Pain duration requirementChronic low back pain of at least six months duration

Device-specific indicationIntended for basivertebral nerves at vertebral levels L3 through S1

Evidence quality notePublished studies are limited, often industry-sponsored; guideline support is weak and contested by some surgical societies

Provider Requirements, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for most invasive pain management procedures described in this policy for non‑Medicare Centene health plans. Prior authorization ensures services meet medical necessity criteria and that only one invasive procedure is performed per visit unless otherwise specified by the Health Plan.

Prior authorization applies to diagnostic, therapeutic and neurolytic procedures unless billing as part of a covered surgical procedure per coding guidance.
Follow the Health Plan's prior authorization submission procedures and use the documented clinical criteria in this policy to support requests.

Prior Authorization

Prior Authorization May Be Required for Referenced Neurolytic/Ablation Codes

Certain neurolytic and ablation CPT codes referenced in this policy may require prior authorization separate from standard nerve block codes. Authorization may be required to confirm that specific neurolytic or ablative criteria are met.

Examples of such CPT codes include neurolytic and ablation codes (e.g., 64620, 64624, 64628, 64629, 64640, 64680) and other listed codes in the CPT section of this policy.
Providers should verify Health Plan-specific prior authorization requirements for neurolytic/ablation procedures before scheduling.

Prior Authorization

Prior Authorization Guidance

This policy is intended to guide medical necessity determinations. Prior authorization decisions will be based on the criteria contained herein and on Health Plan administrative procedures. Providers must document the clinical rationale and supply requested supporting records.

Provide documentation showing how the member meets each applicable criterion in the policy (diagnosis, prior conservative care, response to diagnostic injections, timing between injections, etc.).
Adjudication of authorization requests will consider current evidence, applicable Medicare NCDs/LCDs, and Health Plan-level rules.

Documentation Required

Occipital Block Documentation and Headache Indication Denial Trigger

Occipital nerve block requests must include detailed documentation of the pain distribution, characteristics, prior treatments and objective response to any diagnostic injection. Therapeutic occipital blocks require prior conservative therapy and documented benefit from the diagnostic or initial injection.

Document laterality (unilateral or bilateral), distribution corresponding to greater/lesser/third occipital nerves, and at least two characteristic pain features (e.g., paroxysmal attacks, severe intensity, shooting/stabbing quality).
Record findings such as dysesthesia/allodynia, tenderness over nerve branches or trigger points, prior conservative therapies attempted (heat, rest, PT, NSAIDs, anticonvulsants/tricyclics), and numeric pain score reduction after diagnostic injection.
Therapeutic occipital blocks: show temporary relief from prior injection and ≥3 months of conservative therapy, and limit of no more than four injections in 12 months (including diagnostic).
Occipital nerve blocks for migraine, cervicogenic, or other non‑supported headache types are considered not medically necessary and should be denied.

Documentation Required

CRPS (Sympathetic Block) Documentation Requirements

For complex regional pain syndrome (CRPS) requests involving sympathetic nerve blocks, document specialty involvement, rehabilitation status, prior conservative therapies, objective clinical findings and response to prior blocks when applicable.

Diagnosis should be managed by a pain specialist experienced in CRPS.
Document active rehabilitation regimen and failed ≥3 weeks of conservative therapies (activity modification, exercises, topical agents, oral medical management).
Record two or more objective findings (e.g., hyperalgesia/allodynia, edema/sweating changes, temperature asymmetry >1°C or skin color changes, decreased range of motion/motor dysfunction/trophic changes).
For additional blocks beyond the first or second, document that nerve blocks were given ≥1 week apart and that there was an immediate positive response to the first or second block (e.g., improved temperature ≥1.5°C and decreased pain).
Additional sympathetic blocks without documented benefit from the first or second are not medically necessary.

Documentation Required

Celiac Plexus Documentation and Repeat Procedure Requirements

Celiac plexus nerve block or neurolysis requires documentation of the specific indication and prior therapy status. Repeat celiac procedures have defined time and benefit requirements.

For pancreatic cancer: document diagnosis of pancreatic cancer with severe visceral abdominal/back pain; that strong analgesics (opioids) are no longer effective or have intolerable side effects; and absence of somatic malignancy in the area of innervation (e.g., peritoneum, diaphragm).
For chronic pancreatitis with non‑dilated pancreatic duct: document refractory pain and prior management; a repeat celiac block is medically necessary only if ≥3 months have passed since the prior injection and there was documented clinical benefit (e.g., pain reduction, decreased need for oral analgesia).
Repeat celiac plexus blocks or neurolysis for other unspecified indications are not medically necessary.

Documentation Required

Documentation for Repeat Procedures and Post‑Surgical Pain

For repeat peripheral or intercostal blocks and post‑surgical pain interventions, document prior positive response and improvement in physical and functional status. Repeat procedures should be spaced appropriately and supported by prior benefit.

For post‑herniorrhaphy pain: document diagnosis of post‑herniorrhaphy neuralgia, pain persisting ≥3 months after repair, failure of less invasive measures (NSAIDs/opioids), imaging ruling out non‑neuropathic causes, and that pain is not attributable to other causes.
Therapeutic peripheral nerve blocks require temporary relief from the initial/previous injection and injections given ≥1 week apart when repeated.
For intercostal nerve blocks and other repeat interventions, demonstrate prior responsiveness with functional improvement; repeated blockade may be needed but must be justified by clinical benefit.

Billing Rule

Coding Inclusion Not a Guarantee of Coverage

Inclusion or exclusion of CPT codes in this policy is informational only and does not guarantee coverage. Providers must follow current coding guidance and Health Plan billing rules when submitting claims.

Verify code-specific billing rules and bundling when procedures are performed as part of surgery; peripheral/ganglion nerve blocks administered during surgery may not require separate prior authorization or payment.
Refer to the most up-to-date CPT manuals and Health Plan coding resources prior to claim submission.

Note

Alignment with CMS Coverage

Coverage determinations should be aligned with applicable Medicare national and local coverage determinations and articles when relevant, and Health Plan reviewers may reference CMS resources when evaluating medical necessity.

When applicable, reviewers will consider Medicare NCDs/LCDs and Local Coverage Articles (LCAs) in conjunction with this policy.
Providers should be aware that Medicare coverage positions may influence adjudication for certain procedures and codes.

Key Definitions

inv-35: Occipital neuralgia definition (IHS) — distribution and pain characteristics

IHS definition — pain distributionUnilateral or bilateral paroxysmal, shooting or stabbing pain in the posterior scalp in the distribution of the greater, lesser or third occipital nerves

Associated sensory featuresSometimes accompanied by diminished sensation or dysesthesia in the affected area

Diagnostic blockRelief of pain following a local anesthetic block of the affected nerve is included in diagnostic criteria

inv-36: CRPS — definition and related signs where sympathetic blockade may be diagnostic

Core definitionComplex regional pain syndrome (CRPS): a pain condition where response to sympathetic blockade is diagnostic

Objective signs (require two or more)Hyperalgesia/allodynia; edema and/or sweating changes; temperature asymmetry (>1°C) or skin color changes; decreased range of motion, motor dysfunction or trophic changes

Role of sympathetic blockA technically successful sympathetic block that relieves pain supports diagnosis of CRPS; lack of relief makes CRPS unlikely

inv-37: Genicular nerve procedures — definition (targeting sensory genicular nerves)

Target nervesProcedures targeting sensory genicular nerves that surround the knee and provide joint innervation

Types of interventionsIncludes genicular nerve blocks, neurolysis, and radiofrequency neurotomy

Evidence statusEmerging interventions with limited/conflicting evidence; further research needed to establish safety and efficacy

inv-38: Basivertebral nerve ablation (Intracept) — thermal intraosseous ablation at L3–S1 for Modic-related chronic low back pain

Procedure descriptionThermal intraosseous ablation of basivertebral nerves intended to treat vertebrogenic chronic low back pain

Anatomic levelsDevice intended for ablation of basivertebral nerves at L3 through S1 vertebrae

Target conditionChronic low back pain associated with Modic type 1 or 2 MRI changes of the vertebral endplates

inv-39: Intracept device reference — FDA 510(k) cleared device/system referenced

Device nameIntracept Intraosseous Nerve Ablation System (Relievant Medsystems, Inc.)

Regulatory statusApproved by the U.S. Food and Drug Administration for use with radiofrequency generators for basivertebral nerve ablation

Labeling detailsIntended for ablation of basivertebral nerves L3–S1 and used in conjunction with radiofrequency generators

Required Conservative Therapy Prior to Procedures

must have failed — 3 months / >=3 weeks / >=6 months

Must have failed - 3 months: Therapeutic occipital blocks require failure of three months of conservative treatment including heat/rest/physical therapy (including massage), NSAIDs unless contraindicated, oral anticonvulsants or tricyclic antidepressants, and activity modification3 months

Conservative treatment prerequisite

Must have failed - >=3 weeks: CRPS requires failed ≥3 weeks of conservative therapies (eg, activity modification, exercises, topical lidocaine or capsaicin, and oral medical management such as NSAIDs, antidepressants, anticonvulsants, glucocorticoids) prior to sympathetic block>=3 weeks

Conservative treatment prerequisite

Documentation for basivertebral nerve ablation: Basivertebral nerve ablation intended for chronic low back pain requires documentation of failure to respond to ≥6 months of conservative care AND MRI evidence of Modic type 1 or 2 changes>= 6 months

Imaging and conservative therapy prerequisite

must have failed — >=3 weeks

Must have failed — >=3 weeks (CRPS) summary: CRPS sympathetic block candidates must have failed ≥3 weeks of conservative therapies (see CRPS criteria) prior to first/second block>=3 weeks

See sympathetic block criteria

Injections given at least one week apart: Additional nerve blocks (sympathetic or therapeutic peripheral) should be given at least one week apart when used for symptom control or series treatment>=1 week apart

Frequency spacing requirement

Documentation of failure to respond to >=6 months conservative care and MRI evidence of Modic type 1 or 2 changes

Basivertebral ablation documentation: Documentation must show failure to respond to ≥6 months of conservative care and MRI evidence of Modic type 1 or 2 changes for consideration of basivertebral nerve ablation (Intracept)>= 6 months

Imaging plus conservative care requirement

Frequency and Interval Limits

inv-45: Occipital nerve block — No more than four injections within 12 months (includes diagnostic injection)

12-month limitNo more than four occipital injections within 12 months, inclusive of the diagnostic injection

Includes diagnostic injectionFrequency limit explicitly counts the initial diagnostic injection toward the four-in-12-month limit

Therapeutic prerequisiteTherapeutic blocks require prior temporary relief from an initial injection and failure of three months of conservative therapy

inv-46: Sympathetic nerve block — Blocks given at least one week apart for additional sympathetic blocks

Minimum interval for additional blocksAdditional sympathetic nerve blocks must be given at least one week apart

Requirement for initial managementFirst or second sympathetic block requires CRPS diagnosis, management by an experienced pain specialist, active rehab, and ≥3 weeks of failed conservative therapy

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

inv-47: Celiac plexus block for chronic pancreatitis — Repeat allowed only if >=3 months since prior injection

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

Indication specificityCeliac plexus block is indicated for refractory pain due to chronic pancreatitis with nondilated pancreatic duct

Benefit documentationRepeat block requires documented clinical benefit from the initial celiac block (e.g., pain reduction, elimination of oral analgesia)

inv-48: Celiac plexus neurolysis — Repeat neurolysis not routinely recommended due to low (~30%) effectiveness

Effectiveness of repeat neurolysisRepeat celiac plexus neurolysis for pancreatic cancer is effective only about 30% of the time

Recommendation on repeatsRepeat celiac plexus neurolysis is not recommended routinely due to low effectiveness

Overall pooled effectivenessEUS-guided celiac plexus neurolysis demonstrated pooled pain relief rates of approximately 53–80% for pancreatic cancer

inv-49: Groin nerve blocks/post-herniorrhaphy pain — Repeat every 1–3 weeks until sustained relief if initial response positive

Repeat interval for groin blocksFor post-herniorrhaphy groin neuralgia, injections may be performed every 1–3 weeks until sustained relief if the initial response is positive

Indication timingPost-herniorrhaphy neuralgia suspected when pain persists beyond six to eight weeks; imaging should exclude non-neuropathic causes

Documentation requirementRepeat procedures require documentation of prior positive response to the initial block and improvement in physical/functional status

inv-50: Additional frequency limits (empty inventory summary)

Policy frequency inventoryNo additional frequency limits specified in this section beyond procedure-specific limits noted elsewhere

Provider judgmentProviders should exercise professional medical judgment consistent with standards of practice when determining necessity and intervals

Reference to plan proceduresCoverage decisions are subject to Health Plan procedures, contracts, and applicable state/federal requirements

Imaging and Procedure Guidance

Note

Imaging optional for general nerve blocks

Imaging or radiographic guidance is optional for many general nerve blocks but may be used; follow procedure-specific guidance when imaging is indicated.

Peripheral/ganglion blocks performed as part of surgery follow surgical coding and are not separately payable.
Use imaging guidance as clinically appropriate to increase accuracy and safety.

Billing Rule

Use imaging guidance for intercostal, genicular, celiac, basivertebral procedures

Intercostal, genicular, celiac plexus and basivertebral procedures commonly involve imaging guidance or radiologic monitoring; imaging is recommended or routinely used for these interventions when performed.

CPT descriptions for many of these procedures include imaging guidance ‘when performed’ or radiologic monitoring.
Ultrasound guidance for intercostal blocks can reduce complications such as intravascular injection or pneumothorax.

Documentation Required

Require imaging before diagnostic evaluation for post-herniorrhaphy pain

For evaluation of persistent post-herniorrhaphy groin pain, imaging should be used to exclude non‑neuropathic causes before diagnostic peripheral nerve blocks are performed.

Confirm groin pain persisted ≥3 months after repair and that imaging has ruled out alternative causes prior to diagnostic block.

Note

Procedure-specific imaging guidance for celiac plexus and genicular procedures

Procedure-dependent imaging guidance applies to celiac plexus and genicular nerve procedures; follow the procedure-specific sections of the policy for imaging and technical requirements.

Endoscopic ultrasound-guided celiac plexus interventions are an example where imaging guidance is integral to the procedure.
Refer to procedure-specific criteria for required imaging modality.

Not Medically Necessary / Not Covered Procedures

Occipital nerve blocks for migraine or cervicogenic headaches and several other procedures listed in this policy are designated as not covered / not medically necessary because effectiveness has not been established or evidence is insufficient. Providers should follow the specific coverage criteria in the policy for approved indications, document required conservative therapy and diagnostic response where applicable, and consult applicable state Medicaid or Medicare coverage rules when determining coverage eligibility.

This placeholder reiterates that several nerve block procedures are excluded for certain indications (for example, occipital blocks for migraine/cervicogenic headaches and sympathetic blocks for ischemic limb pain) due to lack of established effectiveness; refer to the policy sections cited for full details.

Duplicate placeholder noting exclusions: clinicians should reference the policy’s specific exclusion statements for procedures lacking evidence (e.g., genicular procedures, basivertebral ablation, peripheral blocks for certain headache types).

Duplicate placeholder reiterating that the policy defines multiple not-covered or investigational nerve block procedures; see the coverage and exclusions sections for precise criteria and rationale.

Duplicate placeholder for the not-covered list: the policy lists specific procedures and indications that are not medically necessary or have insufficient evidence, and providers should document indications that meet covered criteria when applicable.

Duplicate placeholder emphasizing exclusions: occipital and peripheral nerve blocks for certain headache syndromes, sympathetic blocks for ischemic limb pain, genicular and basivertebral procedures are among those called out as not covered or investigational.

Duplicate placeholder restating the policy’s not-covered positions; consult the policy text for exact coverage language, documentation requirements, and any allowed exceptions for specified indications.

There is no single explicit comprehensive list of not-covered procedures in the chunks provided; exclusions and specific coverage decisions are located within the procedure-specific sections of the policy and in state Medicaid or Medicare coverage determinations as applicable.

Clinical Policy: Nerve Blocks and Neurolysis for Pain Management

Sign up for Centene Policy CP.MP.170 alerts

Coverage Criteria for Nerve Blocks and Neurolysis

Coding and Regulatory References

Provider Requirements, Prior Authorization and Documentation

Background and Rationale

Key Definitions

Required Conservative Therapy Prior to Procedures

Frequency and Interval Limits

Imaging and Procedure Guidance

Not Medically Necessary / Not Covered Procedures