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CurrentFidelis CarePolicy CP.MP.170

Clinical Policy: Nerve Blocks and Neurolysis for Pain Management

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Defines medical necessity criteria, limitations, and non-coverage determinations for various nerve block and neurolytic procedures (occipital, sympathetic, celiac plexus, intercostal, genicular, peripheral/ganglion, intraosseous basivertebral nerve ablation) for non‑Medicare Centene-affiliated plans; includes related coding implications.

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Nerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeClarificationsminor criteria updatecoding addition

Effective DateFeb 1, 2025

Last ReviewApr 1, 2024

Next Review Date

Key ActionDocument pancreatic cancer diagnosis, failure or intolerability of strong analgesics, absence of somatic spread (peritoneum/diaphragm), or for chronic pancreatitis document non-dilated pancreatic duct and prior clinical benefit; document ≥3 months interval for repeats.

SourceLink

POLICY UPDATE CHANGES

Added note directing sacroiliac and facet joint interventions to CP.MP.166 and CP.MP.171, respectively, and Medicare plans to MC.CP.MP.170.

Added clarifying verbiage regarding non-Medicare health plans in Policy/Criteria with no impact to criteria.

Updated Criteria II.A.1.c to include topical application of lidocaine.

Added refractory chronic pancreatitis as a medically necessary indication for celiac plexus block.

Added CPT code 64628 (thermal destruction of intraosseous basivertebral nerve).

7Major procedure sections covered

3Insufficient evidence/experimental sections

4Max occipital injections/12 months

30Referenced literature items (partial doc)

Coverage Summary

This policy (Policy Number CP.MP.170, effective date 2025-02-01) defines medical necessity criteria, limits, and non-coverage determinations for a range of nerve block and neurolytic procedures. The coverage stance is mixed: some procedures are supported and covered when specific criteria are met, while others are deemed not medically necessary or have insufficient evidence. Indications addressed include occipital nerve blocks, sympathetic blocks (including for CRPS), celiac plexus block/neurolysis (pancreatic cancer and refractory chronic pancreatitis), intercostal nerve block/neurolysis, genicular interventions, various peripheral/ganglion nerve blocks (including post-herniorrhaphy and malignant pain), and intraosseous basivertebral nerve ablation (Intracept).

Thresholds

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

Sympathetic block temperature responseImmediate positive response example: improved temperature of ≥ 1.5 ⁰C and decreased pain

CRPS diagnostic temperature asymmetry>1°C (evidence of temperature asymmetry as one diagnostic finding)

Medical-Necessity Criteria (by procedure)

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Nerve Blocks and Neurolysis for Pain Management

Policy CodePolicy CP.MP.170

Change TypeClarificationsminor criteria updatecoding addition

Effective DateFeb 1, 2025

Last ReviewApr 1, 2024

Next Review Date

SourceLink

On This Page

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.

Sympathetic Nerve Blocks - Not Medically Necessary

Additional sympathetic nerve blocks without documented benefit from the first or second are not medically necessary.

Sympathetic nerve blocks for any other indication, including ischemic limb pain, are not medically necessary due to lack of evidence.

Celiac Plexus Nerve Block/Neurolysis - Not Medically Necessary

Repeat celiac plexus nerve blocks or neurolysis for any indication other than those noted above are not medically necessary.

Genicular Nerve Blocks/Neurolysis/Radiofrequency Neurotomy - Policy statement about insufficient evidence

Policy statement

Insufficient evidence to determine safety and effectiveness of blocks, neurolysis and radiofrequency neurotomy of the articular/genicular nerve; evidence limited and conflicting.

Peripheral/Ganglion Nerve Blocks - Malignant Pain

Covered as part of a comprehensive program:

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

Peripheral/Ganglion Nerve Blocks - Not Medically Necessary / Insufficient Evidence

Peripheral nerve blocks for prevention or treatment of headaches (including migraine and short-lasting unilateral neuralgiform headaches) are not medically necessary as effectiveness has not been established.

Insufficient evidence to support peripheral nerve blocks for treatment of trigeminal neuralgia.

Insufficient evidence to support peripheral/ganglion nerve blocks or neurolysis for any condition not indicated elsewhere in this policy, including chronic pain.

Intraosseous Radiofrequency Nerve Ablation of Basivertebral Nerve - Policy statement about insufficient evidence

Policy statement

Insufficient evidence to determine the safety and effectiveness of intraosseous radiofrequency nerve ablation of the basivertebral nerve (e.g., Intracept) for treatment of chronic low back pain.

Provider Actions / Billing Impact

Documentation Required

Occipital block diagnostic documentation

Document nerve distribution pain, required pain characteristics (at least two of three), dysesthesia/allodynia, and tenderness or trigger point to meet initial diagnostic criteria. Affected CPT code: 64405.

Required documentation: nerve distribution, ≥2 of 3 pain characteristics, dysesthesia/allodynia, and tenderness or trigger point
Affected code: 64405

Prior Authorization

Limit on number of injections

Ensure no more than four occipital injections (including the diagnostic injection) are provided within any 12-month period. Applicable CPT codes: 64405 and 64999 (unlisted nervous system procedure as applicable).

Limit: ≤4 injections per 12 months (diagnostic injection counts toward limit)
Referenced codes: 64405, 64999

Documentation Required

Therapeutic block response

For therapeutic occipital blocks, document temporary relief from the prior injection (e.g., decreased numeric pain rating) and at least three months of conservative therapy including heat/rest/physical therapy (including massage), NSAIDs unless contraindicated, oral anticonvulsants or tricyclic antidepressants, and activity modification. Affected CPT code: 64405.

Document temporary relief from prior injection (pain score reduction)
Document ≥3 months of conservative therapies (heat/rest/PT/massage; NSAIDs; anticonvulsants or tricyclics; activity modification)
Affected code: 64405

Prior Authorization

Sympathetic block repeat requirement for CRPS

When requesting additional sympathetic blocks beyond the first or second for CRPS, document that prior block produced an immediate positive response (e.g., improved temperature of ≥1.5°C and decreased pain) and that additional blocks are spaced at least one week apart. Affected CPT codes: 64510, 64520.

Document immediate positive response to prior block (example: ≥1.5°C temperature improvement and pain decrease)
Document blocks given at least 1 week apart
Affected codes: 64510, 64520

Documentation Required

Celiac plexus neurolysis criteria

Document diagnosis of pancreatic cancer with severe visceral abdominal/back pain and inadequate analgesia or intolerable opioid side effects, and absence of somatic spread (peritoneum/diaphragm). For chronic pancreatitis, document refractory pain with a non-dilated pancreatic duct and clinical benefit from the initial block. Repeat celiac plexus block for chronic pancreatitis is medically necessary only if ≥3 months have passed since the prior injection and there was documented benefit. Affected CPT codes: 64530, 64680.

Pancreatic cancer criteria: diagnosis, severe visceral pain, opioids ineffective or intolerable, no somatic spread
Chronic pancreatitis: refractory pain with non-dilated duct and documented benefit from prior block
Repeat interval for chronic pancreatitis: ≥3 months since prior injection with documented benefit
Affected codes: 64530, 64680

Billing Rule

PNB during surgery

If peripheral/ganglion nerve blocks are administered as part of another surgical procedure, code per standard coding practice (examples include 64415, 64445, 64447, 64450) and do not submit them separately for prior authorization or separate payment.

Example CPT codes: 64415, 64445, 64447, 64450
Do not submit separately for prior authorization or separate payment when performed as part of another procedure

Denial Risk

Non-covered indications

Claims for nerve blocks for indications deemed not medically necessary may be denied. Examples include occipital nerve blocks for migraine or cervicogenic headaches, sympathetic nerve blocks for ischemic limb pain, and peripheral nerve blocks for prevention or treatment of headaches (including migraine).

Occipital blocks for migraine or cervicogenic headaches: not medically necessary
Sympathetic blocks for ischemic limb pain: not medically necessary
Peripheral blocks for headache prevention/treatment (including migraines): not medically necessary

Documentation Required

Consult applicable NCDs/LCDs and state Medicaid provisions

Providers must review and apply all applicable Medicare NCDs, LCDs, and Medicare Coverage Articles prior to applying these criteria. For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy.

Review applicable Medicare NCDs, LCDs, and Coverage Articles before applying criteria
State Medicaid provisions override this policy where conflicts exist

Documentation Required

Clinical judgment and medical necessity

This clinical policy is a guide to medical necessity and does not dictate care or guarantee payment. Providers are expected to exercise professional medical judgment in treatment decisions.

Policy guides medical necessity determinations but does not guarantee payment
Providers retain responsibility for clinical judgment and treatment decisions

Billing Rule

Policy adoption and effective date awareness

This clinical policy is effective as of the date determined by the Health Plan; the posting date may differ from the effective date. Legal and regulatory requirements govern if there is a discrepancy.

Be aware effective date may differ from posting date
If discrepancies exist, applicable law and regulation govern

Background, Evidence, and Definitions

Guideline and systematic-review evidence supports celiac plexus neurolysis for pain related to advanced pancreatic cancer: a multidisciplinary international guideline issued a strong recommendation based on moderate-quality evidence, and a Cochrane review found significantly reduced opiate use and lower pain versus control. Repeat neurolysis for pancreatic cancer is of limited effectiveness and not routinely recommended.

For other indications the evidence is limited or conflicting. Genicular nerve blocks/neurolysis and genicular radiofrequency neurotomy have limited/conflicting evidence; small studies suggest possible benefit but further research is needed. Peripheral/ganglion nerve blocks for headache prevention/treatment (including migraine and short-lasting unilateral neuralgiform headaches) and for trigeminal neuralgia have insufficient evidence to establish effectiveness.

Intraosseous basivertebral nerve ablation (e.g., Intracept) has an FDA-approved device, but the available clinical evidence is largely industry-sponsored and of generally poor to fair quality; clinical guidelines and reviews provide only weak support and overall there is insufficient evidence to determine safety and effectiveness for vertebrogenic chronic low back pain.

Evidence Item	Summary
Celiac plexus neurolysis - guideline support	Strong recommendation based on moderate quality evidence from a multidisciplinary international guideline for pain associated with advanced pancreatic cancer.
Celiac plexus neurolysis - Cochrane	2011 Cochrane review found celiac plexus block significantly reduced opiate use and lowered pain versus control; meta-analyses report pooled pain relief in 53%–80% of patients with pancreatic cancer for EUS-guided neurolysis.
Genicular interventions	Limited and conflicting evidence; small studies and preliminary trials suggest possible benefit for knee pain but further research is needed to establish safety and efficacy.
Intracept / basivertebral ablation	FDA-approved device (Intracept) exists but evidence is mostly industry-sponsored, limited in size and poor/fair quality; insufficient evidence to determine safety and effectiveness for chronic low back pain.

CRPS: Complex regional pain syndrome (CRPS) — also called reflex sympathetic dystrophy — is defined in this policy as CRPS (aka reflex sympathetic dystrophy).

PNB: Peripheral nerve block (PNB) — procedure involving injection(s) of local anesthetic (with or without steroid) to temporarily interrupt conduction in peripheral nerves for diagnostic or therapeutic purposes.

Type	Number	Name	Effective Date
NCD	MC.CP.MP.170	Peripheral Nerve Blocks and Ablation of Peripheral Nerves for Pain Management (Medicare reference)
LCD	L36850 / L33933	Peripheral nerve blocks	2017-05-01 (L36850), 2015-10-01 (L33933)
LCD	L39420	Thermal destruction of the intraosseous basivertebral nerve (BVN) for vertebrogenic lower back pain	2023-03-05
LCA	A57788	Peripheral nerve blocks (article)	2018-10-03 (revised 2024-10-01)

Revision History

02/25clarified (non-material)Latest

No impact to clinical criteria — Added note directing sacroiliac and facet joint interventions to CP.MP.166 and CP.MP.171 respectively, and for Medicare plans to MC.CP.MP.170 (administrative clarification).

02/25clarified (non-material)Latest

Administrative clarification only — Added clarifying verbiage regarding non‑Medicare health plans in Policy/Criteria with no impact to criteria.

02/25revised (non-material)Latest

Minor wording change to conservative therapy list for CRPS — Updated Criteria II.A.1.c to include topical application of lidocaine (non‑material wording change).

02/25added (material)Latest

Criteria added (material) — Added refractory chronic pancreatitis as a medically necessary indication for celiac plexus block and criteria for repeat injection (>= three months and documented benefit).

08/23added (non-material)

Coding update (non‑material) — Added CPT code 64628 (thermal destruction of intraosseous basivertebral nerve) to referenced CPT list.

08/18revised (non-material)

Administrative/clinical edits (non‑material) — Policy split from CP.MP.118; reworded CRPS diagnostic criteria and added requirement of positive response to first/second block for additional requests; blocks at least one week apart; expanded celiac plexus criteria for pancreatic cancer; changed ischemic leg pain to not medically necessary.

12/21added (non-material)

Added section VII — Insufficient evidence statement for intraosseous radiofrequency basivertebral nerve ablation (document restructuring/title change).

08/22revised (non-material)

Annual review — Added 'as effectiveness has not been established' to occipital nerve block not medically necessary statement; background and minor wording updates.

04/24revised (non-material)

Annual review — Minor rewording and references updated.

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.

Clinical Policy: Nerve Blocks and Neurolysis for Pain Management

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Coverage Summary

Medical-Necessity Criteria (by procedure)

Coding

Provider Actions / Billing Impact

Background, Evidence, and Definitions

Medicare Determinations & References

Revision History