Sympathetic Blockade – Commercial and Individual Exchange Medical Policyopen_in_new

Sympathetic blockade with a local anesthetic is covered (medically necessary) for pancreatic cancer with severe abdominal/back pain and for complex regional pain syndrome (CRPS), and is unproven/not medically necessary for chronic pancreatitis and chronic abdominal or back pain. Coverage requires documentation that InterQual® clinical criteria are met — including detailed treatment history (dates, duration, reasons for discontinuation and treatments tried/failed/contraindicated) — and is subject to member-specific plan benefits and review (documentation does not guarantee payment).

"Sympathetic blockade using a local anesthetic is proven and medically necessary for treating the following indications:"

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