CMM-209: Regional Sympathetic Blocks

Covered: image‑guided (stellate: fluoroscopy or ultrasound; lumbar: fluoroscopy) regional sympathetic blocks using anesthetic and/or corticosteroid/contrast for sympathetically mediated CRPS limited to the extremities; excluded for CRPS outside the extremities and for RFA or chemical neurolysis (phenol/ethyl alcohol) or when guideline requirements aren’t met. Key requirements: strict CRPS criteria (pain disproportionate to inciting event, ≥1 symptom in 3/4 categories and ≥1 sign in 2/4, no other explanatory diagnosis), diagnostic block ≥50% pain reduction with functional improvement for duration of anesthetic to be “positive,” up to 4 diagnostic and 6 therapeutic blocks per 12 months (therapeutic ≤1/week; up to 3 additional diagnostic blocks within 2 weeks after an initial block), required documentation of image guidance, permitted injectates, and therapeutic blocks must be part of a comprehensive pain program with active rehabilitation.

"Initial Diagnostic Regional Sympathetic Block is medically necessary to establish the presence or absence of sympathetically mediated Complex Regional Pain Syndrome (CRPS) when ALL diagnostic crite..."