CMM-209: Regional Sympathetic Blocks

EviCore covers diagnostic and therapeutic stellate and lumbar sympathetic blocks only for sympathetically mediated CRPS of the extremities (CRPS elsewhere is excluded) and deems radiofrequency ablation and chemical neurolysis experimental/unproven. Key requirements: strict diagnostic criteria (disproportionate pain, ≥1 symptom in 3/4 categories and ≥1 sign in ≥2 categories, exclusion of other diagnoses, extremity-limited), a positive diagnostic response (≥50% pain reduction for duration of anesthetic) before additional/therapeutic blocks, therapeutic blocks must show documented prior benefit and be part of a comprehensive pain‑management/rehab program, injectates limited to anesthetic/corticosteroid/contrast, image guidance required (stellate: fluoroscopy or ultrasound; lumbar: fluoroscopy), and utilization limits of up to 10 blocks/12 months (4 diagnostic, 6 therapeutic) with therapeutic blocks ≤1/week and ≤6/year.

"Regional sympathetic blocks performed for a diagnosis of CRPS in the head/face/neck, trunk, perineum/pelvis, or abdominal viscera are considered not medically necessary."