CMM-209: Regional SympatheticBlocks

Regional sympathetic (stellate or lumbar) blocks are medically necessary as an initial diagnostic procedure for sympathetically mediated CRPS (positive = ≥50% pain reduction with functional improvement) and up to three additional blocks within two weeks, with further therapeutic blocks (performed under fluoroscopy, no more than one per week and no more than six total) allowed only as part of a comprehensive pain management/active rehabilitation program with documentation of decreased pain medication use, increased function/tolerance to touch, and diagnosis consistent with IASP/Budapest criteria. They are not covered if done without fluoroscopic guidance, if the patient cannot or will not participate in active rehabilitation, if the diagnostic block fails to produce benefit, or if repeat therapy lacks documented clinical improvement.

"The performance of an initial diagnostic regional sympathetic block is considered medically necessary to establish the presence or absence of sympathetically mediated complex regional pain syndrome."