Nerve Blocks and Neurolysis for Pain Management

This policy covers diagnostic and therapeutic peripheral nerve blocks and neurolytic pain management procedures—such as occipital, sympathetic, celiac plexus, intercostal, peripheral nerve blocks, genicular procedures, and basivertebral intraosseous RFA—when the policy’s specific clinical criteria are met. It applies to conditions like suspected occipital neuralgia, CRPS (first or second sympathetic block with diagnostic findings and failed conservative therapy), severe neuralgic pain from pancreatic cancer, and refractory chronic pancreatitis (non‑dilated duct), and requires physician performance, documented failure of conservative treatments, limits on frequency and number of procedures (e.g., ≤4 occipital injections/12 months, one invasive procedure per visit), with many indications (including migraine prevention, additional sympathetic blocks, and genicular interventions) reviewed case‑by‑case or deemed not medically necessary.

"Diagnostic nerve blocks to identify the peripheral nerve or nerve trunk source of a patient’s pain."