64727
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.02
Facility
$144.96
Non-Facility
$144.96
Documentation Required
- This text is a background/evidence review summarizing clinical studies; it does not list 'Documentation Requirements' such as required medical records, test results, or specific clinical notes.
- Diagnosis of CRPS should be based on the clinical features as determined by history and physical exam using the Budapest Criteria.
- Budapest Criteria components (required documentation for CRPS diagnosis):
- - Continuing pain, which is disproportionate to any inciting event.
Key Coverage Criteria
- Combined transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS) for chronic CRPS (single-case report: left lower limb CRPS type I).
- It is not considered medically necessary to repeat sympathetic blocks more frequently than once every 7 days;
- Continuous epidural analgesia for the treatment of members with intractable CRPS / RSD, when all of the following selection criteria are met: Members have experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications); and Members have failed a trial of physical therapy; and Members have failed a trial of nerve blocks with local anesthetics and steroids;
- Sympathetic blocks (e.g., stellate ganglion block [cervical sympathetic block] and lumbar sympathetic block) for the diagnosis and treatment of sympathetically-maintained pain and/or CRPS when conservative treatments, including analgesia and physical therapy (PT), have failed.
- Up to 3 sympathetic blocks are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect; if the member experiences no pain relief after 3 injections, additional injections are not considered medically necessary.
- Repeat sympathetic blocks for CRPS beyond the first 3 injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes PT, patient education, psychosocial support, and oral medications, where appropriate.
4 Active Policies
AETNA-CPB-0374 — Trigeminal Neuralgia: Treatments
AETNA-CPB-0406 — Tinnitus Treatments
AETNA-CPB-0447 — Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments
AETNA-CPB-0707 — Headaches: Invasive Procedures
Related Codes
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