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Peripheral nerve blocks (peripheral nerve/ganglion injections) - Coverage and clinical criteria

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Coverage and clinical criteria for diagnostic and therapeutic peripheral nerve blocks for Fallon Health products, describing when blocks are medically reasonable and necessary, limitations, exclusions, and variations for Medicare and MassHealth.

Policy Summary

Payerfallon_community_health_plan_inc

PolicyPeripheral nerve blocks (peripheral nerve/ganglion injections) - Coverage and clinical criteria

Policy CodePolicy N/A

Change TypePrior authorization threshold added/operationalized (clarification & formatting updates)

Effective DateSep 1, 2024

Last ReviewSep 23, 2025

Next Review DateSep 23, 2025

Key ActionThe first two nerve blocks in any 12-month period do not require prior authorization; obtain prior authorization for any subsequent nerve blocks within that 12-month period.

SourceLink

POLICY UPDATE CHANGES

The first two (2) nerve blocks in a 12-month period will not require prior authorization; any subsequent nerve blocks during the 12-month period will require prior authorization.

Updated formatting to include new sections for Medicare and MassHealth Variation.

The first two nerve blocks in a 12-month period will not require prior authorization; any subsequent nerve blocks in that 12-month period will require prior authorization.

Updated formatting to include new sections for Medicare and MassHealth Variation during the 09/23/2025 annual review.

2allowed without prior auth (12 mo)

>3denied if > per site (6 mo)

2-3expected injections for resolution

09/01/2024effective date for auth change

03/26/2024,07/02/2024,09/23/2025policy review dates

12RCTs occipital injections

Coverage Criteria for Peripheral Nerve Blocks

inv-01: Medically reasonable and necessary peripheral nerve blocks

Covered when ANY of the following diagnostic or therapeutic situations apply:

Covered indications list: 1) Pain due to classic mononeuritis when neuro-diagnostic studies fail to provide a structural explanation (diagnostic use only). 2) Peripheral nerve injuries/entrapment or extremity trauma leading to complex regional pain syndrome (CRPS). 3) Selective peripheral nerve blockade used diagnostically when the clinical picture is unclear (diagnostic use only). 4) Occipital nerve block to confirm occipital neuralgia (diagnostic use only); if only temporary relief is obtained, neurolysis or further intervention may be considered. 5) Suprascapular nerve block to confirm suspected entrapment (diagnostic use only); may be followed by depot steroid injection. 6) Trigeminal nerve block centrally at the trigeminal ganglion or along peripheral branches for diagnostic or therapeutic purposes. 7) Preemptive analgesia: a) single-injection peripheral nerve block for post-surgical pain control during transition to oral analgesics, for procedures causing severe pain normally uncontrolled by oral analgesics, when IV/parenteral narcotics would otherwise be required, or when the patient cannot tolerate narcotics; b) continuous peripheral nerve block to provide extended relief (e.g., 1–5+ days) for post-surgical analgesia.

inv-02: Limitations on frequency and success criteria

Coverage constrained by frequency and demonstrated benefit:

Policy Summary

Payerfallon_community_health_plan_inc

PolicyPeripheral nerve blocks (peripheral nerve/ganglion injections) - Coverage and clinical criteria

Policy CodePolicy N/A

Change TypePrior authorization threshold added/operationalized (clarification & formatting updates)

Effective DateSep 1, 2024

Last ReviewSep 23, 2025

Next Review DateSep 23, 2025

Key ActionThe first two nerve blocks in any 12-month period do not require prior authorization; obtain prior authorization for any subsequent nerve blocks within that 12-month period.

SourceLink

On This Page

inv-07: Initial interventional coverage criteria

Covered when ALL of the following clinical features and diagnostic responses are documented

ICHD-3 clinical features: Presence of unilateral or bilateral pain in the distribution(s) of the greater, lesser, and/or third occipital nerves with at least two of: paroxysmal attacks lasting seconds to minutes; severe intensity; shooting/stabbing quality; and associated dysesthesia/allodynia with tenderness or trigger points at nerve emergence.

Diagnostic block response: Temporary pain relief after a local anesthetic block of the affected occipital nerve(s) with documentation of duration of relief; because single diagnostic blocks may have false-positive rates up to ~40%, consider a confirmatory second block when diagnostic certainty is required.

Conservative therapy attempted: Documentation of prior conservative measures (e.g., physical therapy, NSAIDs, neuropathic medications, lifestyle measures) unless contraindicated.

Conservative-first approach recommended; blocks used diagnostically and when conservative measures fail.

inv-08: Escalation criteria (e.g., pulsed radiofrequency, ablation)

Continuation or escalation to more invasive treatments when ALL of the following are met

Therapeutic benefit from blocks: Documented clinically meaningful temporary benefit from nerve blocks (for example, patient-reported ≥50% reduction in pain or headache frequency for a clinically relevant interval) or other objective measures demonstrating meaningful improvement.

Many clinicians consider ≥50% reduction at 4 weeks meaningful; trial data and practice patterns vary.

Failure or insufficient duration of less-invasive therapy: Inadequate durable response to repeated nerve blocks or conservative treatments such that escalation to pulsed radiofrequency (PRF), cryoneurolysis, thermal RFA, or surgical options is reasonable.

Randomized and comparative studies suggest some modalities (PRF, cryoneurolysis, botulinum toxin) may offer longer-term benefit than injected anesthetic ± steroid in selected patients.

Conservative Treatment and Documentation Requirements

inv-63: Demonstrate sustained benefit after 1-3 injections; blocks should last at least two months to be deemed successful.

Demonstrate sustained benefit after repeat injections: Blocks should demonstrate sustained benefit after 1–3 injections at the same anatomical site; to be considered successful, relief should generally last at least two months. If progressively sustained relief is not achieved after two to three repeat injections, alternative therapeutic options should be explored.

inv-64: Documented failure to progress with functional restoration before invasive procedures.

Documented failure to progress with functional restoration: Patient has failed to make notable functional improvement with first-line functional restoration (physical and occupational therapy); if significant comorbidities prevent participation in rehabilitation, escalation may be justified with documentation.

Supports requests for escalation to medications, nerve blocks, or interventional therapies.

inv-65: Documentation of trials of conservative therapy prior to advanced interventions unless contraindicated.

Documentation of conservative therapy trials: Document trials of conservative measures (e.g., physical therapy, NSAIDs, neuropathic medications, patient education) prior to advanced interventions unless clearly contraindicated or the patient cannot engage in rehabilitation due to comorbidities.

Diagnostic occipital injections are often repeated prior to more invasive interventions; conservative-first approach recommended.

inv-66: Failure of conservative medical therapy and positive diagnostic blocks prior to surgery — >= 1 year for medications (surgical series)

Failure of conservative medical therapy prior to surgery: For consideration of surgical decompression, documentation typically includes failure of disease-modifying medications for at least 1 year and positive diagnostic occipital nerve blocks (temporary improvement often defined as ≥50%).>= 1 year for medications (surgical series)

inv-67: (placeholder criteria group from chunks related to occipital neuralgia/peripheral nerve blocks)

Occipital neuralgia / peripheral nerve block considerations: Diagnostic features (ICHD-3) and exam findings (tenderness along GON/LON, positive Tinel or 'pillow sign') should be documented; diagnostic local anesthetic blocks are supportive but not specific—false-positives occur with migraine/cluster headache, so clinical correlation and, when needed, repeat blocks or additional evaluation are recommended.

inv-68: Coverage and medical necessity determinations may be influenced by member-specific benefit plan provisions and applicable mandates; no explicit conservative treatment durations are specified in these chunks.

Plan and benefit-plan considerations: Coverage and medical necessity determinations may be influenced by the member's specific benefit plan and applicable state or federal mandates; no explicit conservative treatment durations are specified universally in this policy excerpt—providers should consult the member's Evidence of Coverage and applicable Medicare/MassHealth variations.

Frequency Limits and Quantity Rules

inv-69: peripheral nerve block (specific nerve/anatomic site) — First two blocks in 12 months without prior authorization; more than three injections per anatomic site in 6 months will be denied

Prior authorization allowanceThe first two (2) peripheral nerve blocks in any 12‑month period do not require prior authorization; any subsequent nerve blocks during the same 12‑month period require prior authorization (effective for dates of service on or after 09/01/2024).

Denial threshold per anatomic siteMore than three injections at the same anatomic site (specific nerve/plexus/branch as defined by CPT description) within a 6‑month period will be denied.

Success expectationSigns and symptoms should resolve after one to three injections at a specific site; blocks should last at least two months to be deemed successful.

Multiple site cautionInjections of more than two anatomic sites or frequent/repeated injections are questionable and not supported by peer‑reviewed literature.

inv-70: Sympathetic nerve block (stellate or lumbar) — (source chunk references)

Evidence summaryLocal anesthetic sympathetic (stellate or lumbar) blocks lack high‑quality evidence to define a definitive therapeutic role for CRPS; available studies are small and inconsistent, and benefit may be short‑term.

Clinical roleThese blocks are largely empiric and may be considered in a subset of patients with sympathetically maintained pain to provide a rehabilitation window if they improve pain or function.

Technical noteSympathetic nerve blocks are usually performed with fluoroscopic guidance; defining a 'successful' sympathetic block lacks consensus.

inv-71: Occipital nerve block — Varies in practice; many clinicians repeat injections if patient has sufficient benefit, intervals reported from 1-12 weeks; corticostero...

Practice variabilityIntervals between repeated occipital nerve injections vary widely in practice; many clinicians repeat injections if the patient reports sufficient benefit, with reported intervals from about 1–12 weeks depending on agent and steroid use.

Steroid interval considerationWhen corticosteroid is added, recommended intervals are generally longer (survey respondents reported >11 weeks for steroid‑containing injections).

Diagnostic confirmationSingle diagnostic occipital nerve blocks have false‑positive rates up to ~40%; performance of a second confirmatory block is prudent before definitive interventions or surgery.

inv-72: FREQUENCY LIMITS — Not specified

Frequency limits specifiedNot specified in policy excerpts for some procedures — practice and intervals vary by procedure and clinician preference.

GuidanceWhere specific limits are not provided, clinicians should document clinical response and rationale for repeat procedures; diagnostic injections are often repeated to confirm lack of response prior to escalation.

Imaging/technique noteImaging guidance and technique considerations (ultrasound, CT, fluoroscopy) may influence frequency and repeat‑procedure decisions but are not prescriptive here.

inv-73: nerve blocks (general/peripheral) — 2 nerve blocks

Allowed without prior authorizationTwo (2) nerve blocks are allowed without prior authorization within any rolling 12‑month period.

Prior authorization triggerRequests for more than two nerve blocks within a 12‑month period require prior authorization and may be denied if authorization is not obtained.

Effective dateOperational change effective for dates of service on or after September 1, 2024.

inv-74: nerve blocks — first two procedures do not require prior authorization; subsequent procedures require prior authorization

Authorization workflowThe first two peripheral nerve procedures in a 12‑month period do not require prior authorization; any subsequent procedures within that 12‑month period require prior authorization.

Documentation expectationWhen requesting prior authorization for additional procedures, providers should submit clinical documentation of prior procedures, diagnostic response, and conservative therapy trials.

Denial riskPerforming more than three injections at the same anatomic site within 6 months will be denied regardless of authorization status.

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior authorization limit — first two blocks exempt

The first two nerve block procedures for a member within any 12‑month period do not require prior authorization; any subsequent nerve block(s) during that rolling 12‑month period require prior authorization. This operational change is effective for dates of service on or after September 1, 2024.

Effective policy language: “the first two (2) nerve blocks in a 12‑month period will not require prior authorization. Any subsequent nerve blocks during the 12‑month period will require prior authorization.”

Prior Authorization

Prior authorization — advanced interventional treatments

Interventional, later‑stage procedures (for example, sympathetic nerve blocks and advanced neuromodulation such as dorsal root ganglion stimulation) are treated as more invasive options and should be requested with documentation that first‑line functional restoration therapies were tried and failed or are not feasible.

Policy notes sympathetic nerve blocks and DRG stimulation as later‑stage/advanced interventions.
Requesting documentation should show failure to progress with first‑line functional restoration when applicable.

Prior Authorization

Prior authorization expectation — document prior block response and conservative care

When requesting pulsed radiofrequency or other escalated interventional treatments, provide documentation of prior diagnostic/therapeutic peripheral nerve block response and trials of conservative therapy, since these procedures are expected after less‑invasive options show only temporary benefit.

Policy: “Interventional treatments such as pulsed radiofrequency or more advanced procedures should be considered when diagnostic/therapeutic nerve blocks provide temporary benefit and conservative options have been tried.”
Include documentation of prior block response and conservative therapy trials.

Billing Rule

Coding and prior‑auth expectation for occipital/peripheral nerve procedures

Providers should include appropriate CPT codes from the listed peripheral/occipital nerve procedure code set when submitting requests; obtain prior authorization per payer rules when more than two nerve blocks occur within 12 months.

Policy includes example CPT codes for peripheral/occipital nerve injections (e.g., 64405, 64446, 64454, 64455) for informational use.
Follow prior authorization rules: >2 nerve blocks in 12 months require prior authorization.

Documentation Required

Documentation required — support indication and prior trials

Document the diagnostic or therapeutic indication fully (e.g., mononeuritis, occipital neuralgia, suprascapular entrapment, trigeminal ganglion block, preemptive analgesia) and include prior trials and responses; lack of documentation of indication or prior therapy may result in case‑by‑case review or denial.

Policy: “Documentation should support diagnostic or therapeutic indication … and evidence of prior trials and response.”
Coverage determinations for unspecified indications are adjudicated case‑by‑case.

Documentation Required

Diagnostic documentation — occipital nerve exam and block response

For suspected occipital neuralgia or when evaluating for procedures targeting occipital nerves, document clinical exam findings per ICHD‑3 (tenderness along GON/LON course, Tinel sign, pillow sign) and record temporary pain relief after local anesthetic occipital nerve block, including duration of relief.

Required exam findings: tenderness along GON/LON, positive Tinel sign, pillow sign (policy language).
Document that block produced pain relief at least matching expected anesthetic duration; consider repeating block because single blocks have high false‑positive rates.

Documentation Required

Diagnostic documentation — apply Budapest/IASP criteria and exclude alternatives

When evaluating CRPS, clinical documentation must demonstrate application of IASP/Budapest criteria (continuous disproportionate regional pain; required symptom and sign categories) and explicitly exclude other diagnoses that better explain the findings.

Policy: list of Budapest/IASP diagnostic criteria and statement that diagnosis is excluded by existence of another condition that better explains symptoms.
Document presence of required symptoms/signs and absence of alternative diagnoses.

Documentation Required

Required clinical documentation and success thresholds

Include required clinical details in the record: physical exam findings (tenderness over nerve course, Tinel sign, pillow sign), clear pain characterization per ICHD‑3 for occipital neuralgia, and duration/degree of temporary pain relief after diagnostic local anesthetic block.

Policy: “Clinical documentation should include physical exam findings … description of pain characteristics per ICHD‑3 criteria, and documented temporary pain relief after local anesthetic occipital nerve block (duration at least matching anesthetic effect).”
Frequency/benefit expectations: blocks should last ≥2 months to be deemed successful.

Documentation Required

Candidate selection — medication trial and diagnostic block prior to surgery

Before escalating to surgery for occipital neuralgia, document failure of disease‑modifying medications for at least 1 year and positive diagnostic occipital nerve block responses (≥50% temporary improvement used in surgical series).

Policy: surgical candidates had failed disease‑modifying medications for ≥1 year and required positive diagnostic blocks.
Threshold used in surgical series: ≥50% temporary pain relief.

Billing Rule

Coding and authorization documentation — submit CPTs and prior‑auth when required

Supply CPT coding for the performed procedure(s) with authorization requests; examples listed include 64445, 64446, 64447, 64448, 64449, 64450, 64454, 64455 — and follow prior authorization rules when >2 nerve blocks in 12 months.

Policy: “Providers must submit appropriate CPT coding for peripheral nerve injections/blocks … and follow prior authorization rules when more than two nerve blocks are performed within 12 months.”

Documentation Required

Documentation and references — cite CMS/MassHealth guidance for medical necessity

Include citations and applicable external coverage references when submitting medical necessity arguments for Medicare Advantage or NaviCare members; Fallon follows CMS NCDs/LCDs and MassHealth guidelines as applicable.

Policy: Fallon follows CMS NCDs/LCDs for Medicare Advantage; when absent, Fallon may create internal criteria. For NaviCare, Fallon follows CMS then MassHealth if CMS criteria not met.
Document relevant NCD/LCD or MassHealth guidance when applicable.

Denial Risk

Denial risk — >3 injections at same anatomic site in 6 months

No more than three injections per anatomic site in any six‑month period will be covered; requests exceeding this will be denied.

Policy: “More than three injections per anatomic site … in a six month period will be denied.”

Denial Risk

Denial risk — alternative diagnoses must be excluded

Ensure the diagnosis explicitly excludes other conditions that would better explain the degree of pain and dysfunction; failing to exclude alternatives (given some criteria have low specificity) can lead to misdiagnosis and potential coverage denial.

Policy: Budapest/IASP criteria include exclusion of other diagnoses; the document notes poor specificity of some criteria and risk of misdiagnosis.
Coverage decisions may deny when alternative diagnoses better explain findings.

Denial Risk

Denial risk — single diagnostic block may be insufficient (high false‑positive rate)

Do not rely on a single diagnostic occipital nerve block to confirm diagnosis; single blocks can have false‑positive rates up to ~40%, so a repeat confirmatory block is prudent to support the diagnostic claim.

Policy: “Single diagnostic blocks carry false‑positive rates up to 40%, so the performance of a second block is prudent.”
Policy also states diagnostic injections should be repeated to confirm absence of response before surgery.

Denial Risk

Denial risk — limited evidence for some indications (e.g., CRPS)

Be aware that evidence is limited or uncertain for peripheral nerve blocks in conditions such as CRPS; lack of compelling evidence for therapeutic benefit may result in non‑coverage or denial for those indications.

Policy: “The available evidence relating to the effectiveness of peripheral nerve blocks for CRPS is not compelling.”
Sympathetic nerve blocks lack high‑quality evidence to support a definitive role in CRPS.

Prior Authorization

Prior authorization trigger — >2 blocks/12 months require authorization

Requests for more than two nerve blocks within a rolling 12‑month period may trigger a prior authorization requirement and could be denied if authorization is not obtained.

Policy: “Requests for more than two nerve blocks within a 12‑month period … will require prior authorization.”
Effective date for this operational prior authorization rule: September 1, 2024.

Step Therapy

Stepwise treatment — limit repeats; document alternatives if benefit not sustained

If patient does not achieve progressively sustained relief after two to three repeat injections at the same site, document attempts to explore alternative therapeutic options and provide rationale for continued repeating if requested.

Policy: “If the patient does not achieve progressively sustained relief after receiving two to three repeat peripheral nerve block injections on the same anatomical site, then alternative therapeutic options should be explored.”
Document prior attempts and rationale for any continued repeats.

Step Therapy

Stepwise requirement — document failure of functional restoration before invasive options

Follow a conservative, stepwise approach: document first‑line functional restoration (physical/occupational therapy) attempts and show failure to progress before routinely using nerve blocks except when contraindicated.

Policy: “All treatments focus on functional restoration … physical and occupational therapy are first‑line treatments. The use of medications, psychotherapy and nerve blocks is reserved for patients failing to progress in functional restoration.”

Step Therapy

Conservative‑first expectation — document trials of conservative care

Conservative therapies (rest, hot/cold compresses, physical therapy, NSAIDs, neuropathic medications) should be tried and documented; nerve blocks are generally used for diagnosis and when conservative measures fail or are not feasible.

Policy: “Conservative therapies … are typical first‑line; nerve blocks are used for diagnosis and when conservative measures fail.”
Document trials of conservative care unless contraindicated.

Step Therapy

Conservative progression — repeat diagnostic injections before invasive escalation

Diagnostic anesthetic occipital injections are used to confirm trigger‑site presence and are often repeated prior to more invasive interventions; less‑invasive treatments (nerve blocks, steroid injections) should typically precede pulsed radiofrequency or surgery.

Policy: “Before occipital nerve surgery, anesthetic injections are utilized to confirm occipital trigger site presence. These diagnostic injections should be repeated to confirm an absence of response to injection.”
Policy describes PRF and other modalities as later options after less‑invasive treatments.

Note

Step therapy — follow Medicare/MassHealth and member benefit provisions

No explicit automated step‑therapy algorithm is specified in this policy; coverage determinations will follow applicable Medicare/MassHealth guidelines and member benefit plan provisions when present.

Policy: “No explicit step therapy rules are specified … coverage determinations follow Medicare/MassHealth guidelines and member benefit plan provisions.”

Note

Coding Guidance and Code Lists

CPT codes listed (informational)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
64418	Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed
64420	Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve
64421	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level
64425	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level
64435	Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves
64445	Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve

1–10 of 17

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Example CPT Codes for Peripheral Nerve ProceduresCPT

64445	Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve.
64446	Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed.
64447	Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed.
64448	Injection(s), anesthetic agent(s); femoral nerve, including imaging guidance, when performed.
64449	Injection(s), anesthetic agent(s); femoral nerve, continuous infusion by catheter (including catheter placement), including imaging guidance, when.
64450	Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed.
64454	Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch.
64455	Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed.

inv-24: Diagnostic block validation — Consider repeat block due to single-block false-positive rates up to 40%

False‑positive rate concernSingle diagnostic blocks can have false‑positive rates up to approximately 40%; repeat block(s) should be considered to validate diagnostic response.

ImplicationBecause of high single‑block false‑positive rates, a second confirmatory block is prudent before major interventions or surgery.

Diagnostic aimRepeat diagnostic blocks help distinguish placebo or non‑specific headache responses from true nerve‑mediated pain relief.

inv-25: Diagnostic block response threshold — ≥50% temporary pain relief used as a positive diagnostic response in surgical series

Surgical series diagnostic thresholdA temporary improvement of ≥50% (≥50% reduction in pain) after a diagnostic local anesthetic block is used as a positive diagnostic response in cited surgical series.

Use in candidate selectionMany surgical decompression series required diagnostic blocks showing ≥50% temporary improvement before proceeding to surgery.

DocumentationDuration of relief should at minimum match the expected anesthetic effect and be documented in the record.

inv-26: Nerve block count threshold — greater than 2 nerve blocks within 12 months triggers prior authorization

Authorization trigger thresholdMore than two (2) nerve blocks within a rolling 12‑month period triggers a prior authorization requirement; requests exceeding this may be denied without authorization.

Denial for excessive same‑site injectionsMore than three injections at the same anatomic site within 6 months will be denied.

Operational notePolicy update effective 09/01/2024 formalized the <=2 blocks without prior authorization rule.

Definitions

inv-52: Peripheral nerve block — An injection of a local anesthetic, with or without a steroid, into a peripheral nerve or nerve ganglion to temporarily interrupt conduct...

DefinitionPeripheral nerve block: an injection of a local anesthetic, with or without a steroid, into a peripheral nerve or nerve ganglion to temporarily interrupt conduction of impulses and block pain signals.

PurposeUsed for diagnostic confirmation, therapeutic pain relief, or preemptive analgesia around surgical procedures.

Typical agentsLocal anesthetics (e.g., lidocaine, bupivacaine) often used; corticosteroids may be added in some therapeutic injections.

inv-53: Complex Regional Pain Syndrome (CRPS) — A chronic neuropathic pain disorder with autonomic features that typically develops after acute tissue trauma and includes burning pain, ...

Definition summaryComplex Regional Pain Syndrome (CRPS): a chronic neuropathic pain disorder with autonomic features that typically develops after acute tissue trauma, includes burning pain, hyperalgesia/allodynia, edema, vasomotor and sudomotor changes, trophic changes, and motor dysfunction; subdivided into CRPS‑I (no documented nerve injury) and CRPS‑II (documented nerve injury).

Clinical featuresCRPS is characterized by continuous disproportionate regional pain and variable progression with sensory, vasomotor, sudomotor/edema, and motor/trophic abnormalities.

Diagnostic requirementDiagnosis requires exclusion of another condition that better explains the symptoms; Budapest/IASP criteria are applied.

inv-54: CRPS — A chronic neuropathic pain disorder with autonomic features, regional disproportionate pain, and associated sensory, vasomotor, sudomotor...

CRPS description (expanded)CRPS: a chronic neuropathic pain disorder with regional disproportionate pain and associated sensory, vasomotor, sudomotor/edema, motor/trophic findings; retains subtypes CRPS‑I and CRPS‑II based on presence of documented nerve injury.

Evidence noteThere is no definitive medical treatment and many trials have failed to show consistent efficacy of commonly used interventions; sympathetic blocks have limited/uncertain efficacy in CRPS.

Clinical implicationConsider multidisciplinary approaches; documentation must exclude alternative diagnoses per Budapest criteria before interventions aimed at CRPS.

inv-55: Occipital neuralgia — Paroxysmal shooting or stabbing pain in the posterior scalp in the distribution of the greater, lesser, or third occipital nerves, often ...

Clinical definitionOccipital neuralgia: paroxysmal shooting or stabbing pain in the posterior scalp in the distribution of the greater, lesser, or third occipital nerves, often with tenderness and possible dysesthesia; GON pathology accounts for ~90% of cases.

Common causesMay be caused by nerve compression, muscle tightness, cervical spondylosis, trauma, or less commonly tumors, vascular or inflammatory conditions.

Associated featuresPatients may have pain radiating over the cranium, positive Tinel sign, and trigger points at nerve emergence; differential includes migraine and cervicogenic headache.

inv-56: (ICHD-3 occipital neuralgia criteria) — Unilateral or bilateral paroxysmal shooting/stabbing pain in the distribution of the greater, lesser, and/or third occipital nerves, often with dysesthesia, tenderness, and temporary relief with local anesthetic nerve block (ICHD-3 criteria).

ICHD‑3 criteria (summary)Unilateral or bilateral paroxysmal shooting/stabbing pain in the distribution of the greater, lesser, and/or third occipital nerves, often with dysesthesia, tenderness, and temporary relief with local anesthetic nerve block (per ICHD‑3).

Diagnostic requirementPain eased temporarily by local anesthetic block of the affected nerve(s) and not better accounted for by another ICHD‑3 diagnosis.

Clinical characteristicsPain has at least two characteristics (paroxysmal attacks, severe intensity, shooting/stabbing quality) and is associated with dysesthesia/allodynia and tenderness or trigger points.

inv-57: Diagnostic occipital nerve block — A temporary local anesthetic injection to the greater and/or lesser occipital nerve producing temporary improvement (often ≥50%) used to ...

Diagnostic occipital block definitionA temporary local anesthetic injection to the greater and/or lesser occipital nerve producing temporary improvement (often ≥50%) used to confirm occipital neuralgia diagnosis.

UtilityPositive temporary response to diagnostic occipital nerve block is a required element of ICHD‑3 diagnosis and is used to select candidates for further interventions.

Confirmatory practiceBecause single blocks have high false‑positive rates, repeat diagnostic blocks are often used to confirm the diagnosis prior to invasive procedures.

inv-58: Pulsed radiofrequency (PRF) — A nondestructive radiofrequency technique delivering short bursts of high-amplitude current with pauses to limit heat, intended to provid...

Technique summaryPulsed radiofrequency (PRF) is a nondestructive radiofrequency technique delivering short bursts of high‑amplitude current with pauses to limit heat, intended to provide analgesia without creating a destructive lesion.

Clinical rolePRF has been shown in some studies to produce statistically significant improvements in pain scores and quality of life for occipital neuralgia and may be considered when blocks provide temporary benefit.

Comparison notePRF is nondestructive compared with thermal RFA; evidence suggests PRF may provide longer benefit than steroid injections in some trials.

inv-59: Thermal radiofrequency ablation (RFA) — Application of radiofrequency energy producing thermal lesions in neural tissue with potential neural disruption and analgesic effect.

DefinitionThermal radiofrequency ablation (RFA): application of radiofrequency energy producing thermal lesions in neural tissue with potential neural disruption and analgesic effect.

Clinical outcomesThermal RFA series report mean pain relief durations in the months range (one series reported mean relief ~6.5 months) and significant short‑term reductions in VAS scores.

Risk/benefitThermal RFA produces neural lesions and is more destructive than PRF; candidate selection and expected duration of benefit should be documented.

inv-60: Occipital neuralgia / peripheral nerve blocks — Clinical entity and interventional treatments for occipital neuralgia and peripheral neuropathic pain are discussed across multiple cited...

Scope of discussionThe policy discusses occipital neuralgia and peripheral nerve blocks across multiple evidence sources, covering diagnostic criteria, blockade techniques, and neuromodulation options.

Evidence baseReferences include randomized trials, systematic reviews, case series, and guideline statements supporting selective use of injections, PRF, RFA, and surgery based on diagnostic block response and failure of conservative therapy.

Clinical sequencingDiagnostic blocks are commonly used to confirm trigger sites; persistent benefit and failure of conservative measures inform escalation to PRF, ablation, or surgery.

inv-61: NaviCare — For NaviCare members, Fallon first follows CMS NCDs/LCDs and applicable Medicare statutes/regulations; if criteria are not met or absent,...

NaviCare ruleFor NaviCare members, Fallon first follows CMS NCDs/LCDs and applicable Medicare statutes/regulations; if those criteria are not met or absent, Fallon then follows MassHealth Medical Necessity Guidelines.

Implication for prior authorizationWhen Medicare LCD/NCD criteria apply, those rules take precedence for coverage and authorization decisions for applicable members.

PACE notePACE participants require interdisciplinary team authorization for services except emergency and out‑of‑area urgent care.

inv-62: PACE — PACE participants receive care authorized by an Interdisciplinary Team; except for emergency and out-of-area urgent care, all services mu...

PACE authorizationPACE participants receive care authorized by an Interdisciplinary Team; except for emergency and out‑of‑area urgent care, all services must be authorized by that team.

Coverage implicationPACE authorization processes may supersede routine prior authorization pathways for some services as determined by the interdisciplinary team.

Member scopeCoverage for PACE members follows Medicare/Medicaid entitlements plus additional services authorized by the team.

Not Covered / Exclusions

Peripheral nerve blocks for chronic neuropathic pain are categorized as not covered / not medically necessary in this policy excerpt. Additionally, routine local anesthetic sympathetic blockade (LASB) for CRPS lacks sufficient high‑quality evidence to be supported as a standard effective therapy; randomized and comparative studies are few, small, and inconsistent in demonstrating benefit.

The policy reiterates that peripheral nerve blocks for chronic neuropathic pain are not covered and emphasizes limited evidence for LASB in CRPS. Where evidence is sparse or conflicting, the policy treats therapeutic use as unsupported pending further research.

As stated in the exclusions and evidence analysis, peripheral nerve blocks offered for chronic neuropathic conditions—including CRPS—are not supported by the current literature; the policy therefore does not endorse their routine therapeutic application for these indications.

The policy's not‑covered stance on chronic neuropathic pain reflects the absence of convincing evidence for sustained benefit; for CRPS in particular, systematic reviews conclude that LASB has not demonstrated clear efficacy.

Clinical and systematic evidence summarized in this policy support a conservative approach: peripheral nerve blocks are not covered for chronic neuropathic pain and LASB for CRPS is not established as an effective standard therapy given current data limitations.

The excerpt does not list a comprehensive set of explicitly not‑covered procedures, but it operationalizes utilization controls: the first two nerve blocks in any 12‑month period do not require prior authorization; additional nerve blocks within that 12‑month period require prior authorization and may be denied if authorization is not obtained.

Coverage may be restricted by the member's benefit plan or employer group; exceptions and exclusions specific to products are not listed here and providers should verify coverage in the member's Evidence of Coverage. CPT examples are provided for informational purposes but do not guarantee coverage for all products.

Peripheral nerve blocks (peripheral nerve/ganglion injections) - Coverage and clinical criteria

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Coverage Criteria for Peripheral Nerve Blocks

Conservative Treatment and Documentation Requirements

Frequency Limits and Quantity Rules

Provider Actions, Authorization, and Documentation

Coding Guidance and Code Lists

Imaging and Guidance Recommendations

Background and Clinical Context

Definitions

Not Covered / Exclusions