Subject:
Regional Sympathetic Blocks
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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CMM-209.1 Definitions
† Regional sympathetic blocks (i.e., Stellate Ganglion Blocks and Lumbar Sympathetic Blocks) refer to the injection of local anesthetic along the sympathetic ganglia of the under fluoroscopy to reduce sympathetic nervous system activity. A diagnostic regional sympathetic block is considered positive when there is significant reduction in pain and improvement in function for the duration of the local anesthetic used.
† Complex Regional Pain Syndrome (CRPS) is defined by the International Association for the Study of Pain (IASP) as a variety of painful conditions following injury which appear regionally having a distal predominance of abnormal findings, exceeding in both magnitude and duration the expected clinical course of the inciting event and often resulting in significant impairment of motor function, and showing variable progression over time. In addition to injury, CRPS can also occur as a result of various medical disorders or illnesses. The diagnostic criteria for CRPS are as follows:
® Continuing pain that is disproportionate to any inciting event
® Must report at least one (1) of the symptoms in the following categories:
¡ Sensory: reports of hyperesthesia
¡ Vasomotor: reports of temperature asymmetry, skin color changes, and/or skin color asymmetry
¡ Sudomotor/edema: reports of edema, sweating changes, and/or sweating asymmetry
¡ Motor/trophic: reports of decreased range of motion, motor dysfunction (weakness, tremor, dystonia), and/or trophic changes (hair, nail, skin).
® Must display at least one (1) of the signs on physical examination in TWO or MORE the following categories:
¡ Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch)
¡ Vasomotor: evidence of temperature asymmetry, skin color changes, and/or asymmetry
¡ Sudomotor/edema: evidence of edema, sweating changes, and/or sweating asymmetry
¡ Motor/trophic: evidence of decreased range of motion, motor dysfunction (weakness, tremor, dystonia). and/or trophic changes (hair, nail, skin).
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-209.2 General Guidelines
† The determination of medical necessity for the performance of regional sympathetic blocks is always made on a case-by-case basis.
† Please note: this guideline does not apply to injections/blocks of other autonomic nerves (e.g. sphenopalatine ganglion, carotid sinus, superior hypogastric plexus, celiac plexus, Gasserian ganglion [trigeminal nerve], splanchnic nerve, Ganglion of Impar, rami communicans).
† Regional sympathetic blocks should be performed using fluoroscopy.
† Due to insufficient evidence that regional sympathetic blocks (Stellate Ganglion Blocks and Lumbar Sympathetic Chain Blocks) performed as an isolated treatment alter the long term outcome of CRPS, all regional sympathetic blocks in recalcitrant cases of CRPS should be performed with the intent of facilitating involvement and advancement in an active rehabilitation/functional restoration program.
CMM-209.3 Indications
† 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. A positive response is defined as at least 50% reduction in pain and improvement in function for the duration of the local anesthetic used.
† Following a successful initial diagnostic block, three (3) additional regional sympathetic blocks, performed within the first two (2) weeks of the initial block, may be considered medically necessary to diagnose the individual’s pain and obtain a therapeutic response.
† Additional therapeutic regional sympathetic blocks are considered medically necessary when provided as part of a comprehensive pain management program and ALL of the following criteria are met:
® Decreased use of pain medication
® Increased functional ability (e.g., increased range of motion, strength, and use of the extremity in activities of daily living)
® Increased tolerance to touch (e.g., decreased allodynia)
® Ongoing participation in an active rehabilitation program
® Performed at a frequency of no more than one time per week
® No more than six (6) total blocks
CMM-209.4: Non-Indications
Regional sympathetic blocks are considered not medically necessary for each of the following:
† When the individual is not capable of participating or is not involved in an ongoing active rehabilitation program
† Without the use of fluoroscopic guidance
† No significant reduction in pain and no improvement in function for the duration of the local anesthetic following the diagnostic block
† A repeat therapeutic block when there is no decrease in use of pain medication, increase in functional ability, and increase of tolerance to touch
CMM-209.5 Procedure (CPT®) Codes
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| This policy relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. |
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| Code Description/Definition |
| 64510 | Injection, anesthetic agent; stellate ganglion(cervical sympathetic) |
| 64520 | Injection, anesthetic agent; lumbar or thoracic(paravertebral sympathetic) |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of Horizon BCBSNJ and is based on the member’s policy or benefit entitlement structure as well as claims processing rules. |
Medicare Coverage:
There is no National Coverage Determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for Regional Sympathetic Blocks. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Regional Sympathetic Blocks
Sympathetic Blocks for the Treatment of Complex Regional Pain Syndrome (CRPS)
Sympathetic Block
Complex Regional Pain Syndrome
CRPS
Stellate Ganglion Block
Cervical Sympathetic Block
Paravertebral Sympathetic Block
Lumbar Sympathetic Block
Thoracic Sympathetic Block
References:
1. Ackerman W. Zhang J. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome. Southern Medical Journal. 2006;99(10):1084-1088.
2. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008.
3. American Medical Association. Current Procedural Terminology – Professional Edition.
4. Cepeda M, Carr D, Lau J. Local anesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev. 2005 Oct 19;4:CD004598.
5. Cepeda M, Lau J, Carr D. Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: a narrative and systematic review. Clin J Pain. 2002;18:216-233.
6. Chou R, Huffman L. American Pain Society. American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2007;147(7):505-14.
7. Chou R, Huffman LH American Pain Society. American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American PainSociety/American College of Physicians clinical practice guideline. Annals of Internal Medicine.2007;147(7):492-504.
8. Chou R, Qaseem A, Snow V, et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. American College of Physicians. American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7):478-491.
9. Chou R. Using evidence in pain practice: Part I: Assessing quality of systematic reviews and clinical practice guidelines. Pain Medicine.2008; 9(5):518-530.
10. Forouzanfar T, Köke A, van Kleef M, Weber W. Treatment of complex regional pain syndrome type I. Eur J Pain. 2002;6:105-122.
11. Furlan A, Mailis A, Papagapiou M. Are we paying a high price for surgical sympathectomy? A systemic literature review of late complications. J Pain. 2000;1:245-257.
12. Galer B, Bruehl S, Harden R. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. Clin J Pain. 1998;14:48–54.
13. Harden R, Bruehl S, Galer B, et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain 1999;83:211-219.
14. Harden R, Bruehl S, Perez R, et al. Validation of proposed diagnostic criteria (the “Budapest criteria”) for complex regional pain syndrome. PAIN 2010:150:268 – 74.
15. Harden R, Bruehl S, Stanton-Hicks M, Wilson P. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med. 2007;8(4):326-331.
16. Hartrick C, Kovan J, Naismith P. Outcome prediction following sympathetic block for complex regional pain syndrome. Pain Pract. 2004;4:222-228.
17. Harvey AM. Classification of chronic pain – descriptions of chronic pain syndromes and definitions of pain terms. Clin J Pain 1995; 11(2); 179.
18. Janig W, Baron R. Complex regional pain syndrome: mystery explained? Lancet Neurol. 2003;2;687-697.
19. Leis S, Weber M, Schmelz M, Birklein F. Facilitated neurogenic inflammation in unaffected limbs of patients with complex regional pain syndrome. Neurosci Lett. 2004;359:163-166.
20. Ozturk E, Mohur H, Arslan N, et al. Quantitative three-phase bone scintigraphy in the evaluation of intravenous regional blockade treatment in patients with stage-I reflex sympathetic dystrophy of upper extremity. Annals of Nuclear Medicine. 2004;18(8):653-658.
21. Paraskevas K, Michaloglou A, Briana D, Samara M. Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine. Clin Rheumatol. 2005;7:1-7.
22. Perez R, Kwakkel G, Zuurmond W, de Lange J. Treatment of reflex symathetic dystrophy (CRPS type 1): a research synthesis of 21 randomized clinical trials. J Pain Sympt Management. 2001;21:511-526.
23. Schurmann M, Gradl G, Wizgal I, et al. Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I. Clin J Pain. 2001;17:94-100.
24. Severens J, Oerlemans H, Weegels A, et al. Cost-effectiveness analysis of adjuvant physical or occupational therapy for patients with reflex sympathetic dystrophy. Arch Phys Med Rehabil.1999;80:1038–1043
25. Sharma A, Williams K, Raja S. Advances in treatment of complex regional pain syndrome:recent insights on a perplexing disease. Curr Opin Anaesthesiol. 2006;19:566-72.
26. Stanton-Hicks M. A report on the 2nd IASP Research Symposium, Cardiff, Wales. Complex regional pain syndrome: current research on mechanisms and diagnosis. In: International Association for the Study of Pain. Special Interest Group on Pain and the Sympathetic Nervous System. 2000; 1– 2.
27. Stanton-Hicks M. In: Wakefield CA, Bajwa JH. Principles and Practice of Pain Medicine. 2nd ed.2004.
28. Stanton-Hicks M, Baron R, et al. Consensus report: complex regional pain syndromes: guidelines for therapy. Clin J Pain. 1998;14:155–166
29. Stanton-Hicks M, Burton A, Bruehl S, et al. An updated interdisciplinary clinical pathway for CRPS: report of an expert panel. Pain Practice. 2005;84(3):S4-S16.
30. Stanton-Hicks M. Complex regional pain syndrome: manifestations and the role of neurostimulation in its management. J Pain Symptom Manage. 2006;(4 Suppl):S20-S4.
31. Suresh S, Wheeler M, Patel A. Case series: IV regional anesthesia with ketorolac and lidocaine: is it effective for the management of complex regional pain syndrome 1 in children and adolescents? Anesth Analg. 2003;96:694-695.
32. Turner J, Loeser J, Deyo R, Sanders S. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications. Pain. 2004;108:137-147.
33. Varrassi G, Paladini A, Marinangeli F, Racz G. Neural modulation by blocks and infusions. Pain Pract. 2006;6:34-38.
34. Wang L, Chen H, Chang P, et al. Axillary brachial plexus block with patient controlled analgesia for complex regional pain syndrome type I: a case report. Reg Anesth Pain Med. 2001;26(1):68-71.
35. Workloss Data Institute. Official Disability Guidelines 2009.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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