![]() Tumor necrosis factor-α antagonists (e.g.Number: 0236 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References.Transcranial direct current stimulation.Multi-site continuous peripheral nerve catheters.Movement representation techniques (e.g., action observation, mirror visual feedback/mirror therapy, and motor imagery).Ketamine metabolite (2R,6R)-hydroxynorketamine.Combined transcranial direct current stimulation and transcutaneous electrical nerve stimulation.Combined dorsal root ganglion stimulation and dorsal column spinal cord stimulation.Bio-Electro-Magnetic-Energy-Regulation (BEMER) magneto-therapy.The following approaches for the treatment of CRPS (not an all-inclusive list):.Neurolysis of the spinal accessory nerve in the treatment of CRPS and post traumatic chronic pain syndrome.Intrapleural analgesia for the treatment of CRPS with chronic pain involving the thoracic dermatomes.Intravenous administration of guanethidine, ketamine (including "ketamine coma" - extended use of ketamine at anesthetic dosages), lidocaine or midazolam for the treatment of CRPS, other types of chronic pain, and depression.Note: For clinical diagnostic criteria for complex regional pain syndrome, see Appendix for the Budapest Criteria.Īetna considers the following interventions experimental and investigational for CRPS / RSD because the effectiveness of these approaches has not been established: For doral root ganglion stimulation for CRPS, see CPB 0194 - Spinal Cord Stimulation. Dorsal column stimulators (DCS) medically necessary durable medical equipment (DME) for the management of CRPS when the member meets all of the criteria listed in CPB 0194 - Spinal Cord Stimulation. ![]() It is not considered medically necessary to repeat sympathetic blocks more frequently than once every 7 days Repeat sympathetic blocks for CRPS beyond the first 3 injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes PT, patient education, psychosocial support, and oral medications, where appropriate. Up to 3 sympathetic blocks are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect if the member experiences no pain relief after 3 injections, additional injections are not considered medically necessary. Sympathetic blocks (e.g., stellate ganglion block and lumbar sympathetic block) for the diagnosis and treatment of sympathetically-maintained pain and/or CRPS when conservative treatments, including analgesia and physical therapy (PT), have failed.Members have failed a trial of nerve blocks with local anesthetics and steroids Īetna considers continuous epidural analgesia experimental and investigational for the treatment of CRPS when criteria are not met.Members have failed a trial of physical therapy and.Members have experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications) and.Continuous epidural analgesia for the treatment of members with intractable CRPS / RSD, when all of the following selection criteria are met:.This Clinical Policy Bulletin addresses treatments for complex regional pain syndrome (CRPS) / reflex sympathetic dystrophy (RSD).Īetna considers the following interventions medically necessary for complex regional pain syndrome (CRPS), formerly referred to as reflex sympathetic dystrophy (RSD), when criteria are met: (Replaces CPB 550) Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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