Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain Form

Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses the use of peripheral nerve blocks for the treatment of chronic neuropathic pain that results from peripheral neuropathy. Peripheral nerve blocks consist of injections of local anesthetics, with or without adjuvants (such as steroids), near peripheral nerves or nerve ganglia. The goal of peripheral nerve blocks, which can be given as a single injection or a series of injections, is to block pain signals to the brain and thereby provide temporary pain relief.

Note: This document does not address ablative procedures, such as destruction by neurolytic agents (chemical, thermal, electrical or radiofrequency ablation), neurectomy (also called a surgical nerve block), radiosurgery or regional sympathetic nerve blocks.

Note: This document does not address nerve blocks for treatment of the following indications:

  • Nerve entrapment syndromes, such as carpal tunnel, cubital tunnel, radial tunnel or tarsal tunnel syndromes.
  • Impingement syndromes, such as shoulder impingement syndrome.
  • Neuromas, such as Morton’s Neuroma.
  • Surgical pain, postoperative pain, pain caused by acute trauma and other nociceptive pain.
  • Complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD).

Note: For more information on related topics, please see the following:

  • CG-DME-04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous
  • CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures
  • CG-SURG-25 Injection Treatment for Morton’s Neuroma
  • CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • SURG.00112 Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)
  • SURG.00142 Genicular Procedures for Treatment of Knee Pain
  • SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

Position Statement

Investigational and Not Medically Necessary:

Peripheral nerve blocks are considered investigational and not medically necessary for management of neuropathic pain, including but not limited to treatment of any of the following:

  • Chemotherapy-induced peripheral neuropathy (CIPN);
  • Chronic nonmalignant pain;
  • Peripheral neuropathy (for example, diabetic neuropathy, HIV-related neuropathies, etc.);
  • Trauma induced neuropathy.

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