General Information
It is an expectation that all patients receive care/services from a licensed clinician.  All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline focuses on the utilization management of sympathetic nerve blocks for the diagnosis and acute and chronic management of sympathetically maintained pain for specific indications.

Special Note
Sympathetically maintained pain is a symptom of neuropathic pain. The pain is driven by overactivity of the sympathetic nervous system with or without an identifiable injury and is notably characterized as a clinical syndrome called complex regional pain syndrome (CRPS); but may also occur from neuropathic pain syndromes of different etiologies. Sympathetic nerve blocks provide diagnostic value in the identification of sympathetically maintained pain and the focused location of nerves along the spinal column provide a targeted advantage. These blocks are widely used in both acute and chronic management of sympathetically maintained pain of visceral, ischemic, and neuropathic etiologies.

New Episodes of Care
Any injection performed at least two years from prior injections in the same region will be considered a new episode of care and the INITIAL injection requirements must be met for approval. Events such as surgery on the same spinal region or any new pathology would also prompt a new episode of care

Indications
General Indications

• Acute or chronic noncancer pain causing functional disability or average pain level of ≥ 6 on a scale of 0 to 10 prior to injection AND continuation of pain or functional disability after the relief period due to the block
• Cancer pain affecting quality of life prior to injection and continuation after the relief period due to the block ⁽¹⁾

NOTE: It is generally considered NOT MEDICALLY NECESSARY to perform multiple interventional pain procedures on the same date of service (e.g., diagnostic block and neurolytic procedure)

NOTE: Each block must be performed under image guidance ^(2,3)

Indications for Stellate Ganglion Block

Applies to face, upper extremities and upper thoracic region ⁽⁴⁾

Diagnostic Evaluation or Acute Management of Sympathetically Maintained Pain Resulting From:

• Acute Herpes Zoster (shingles) for prevention of postherpetic neuralgia ⁽⁵⁾ AND
  • Pain duration less than 4 weeks, AND
  • Active antiviral therapy regimen or documented medical reason unable to tolerate
• Cancer pain or phantom limb pain ⁽²⁾ AND
• Failure to respond to nonoperative conservative treatment pertinent to the diagnosis or a clearly documented medical reason the conservative treatment cannot be done
• The previous block resulted in at least 50% relief or significant documented functional improvement for at least the duration of the anesthetic

NOTE: Up to 6 sympathetic blocks may be performed per 12 months

Diagnostic Evaluation, Acute or Chronic Management of Sympathetically Maintained Pain Resulting From:

• Complex regional pain syndrome types I ⁽⁶⁾ and II ⁽⁷⁾ meeting Budapest criteria, AND
  • Failure to respond to functional restoration modalities which may include physical therapy, occupational therapy, or pain psychology modalities (e.g. rehabilitation strategies such as desensitization, range of motion, biofeedback, etc) or clearly documented medical reason the patient is unable to participate
  • Active participation in ongoing functional restoration or a clearly documented medical reason the treatment cannot be done⁽²⁾
• The previous block resulted in at least 50% relief or significant documented functional improvement for at least the duration of the anesthetic

NOTE: During the initial treatment phase, a total of 6 blocks may be performed within the first 12 weeks. Following the initial treatment phase, a maximum of 4 sympathetic nerve blocks may be performed in a 12-month period

General Limitations

• It has been at least one week since the prior injection in the same or different region
• Bilateral stellate ganglion blocks will not be performed on the same day of service

Contraindications

• Patient refusal
• Local or systemic infection
• Coagulopathy or recent myocardial infarction
• Contralateral pneumothorax or severe emphysema
• Contralateral palsy of recurrent laryngeal nerve or phrenic nerve
• Allergy to anesthetic medication

Indications for Thoracic or Lumbar Sympathetic Block

Applies to thoracic region and lower extremities ⁽⁴⁾

Diagnostic Evaluation or Acute Management of Sympathetically Maintained Pain Resulting From:

• Acute Herpes Zoster (shingles) for prevention of postherpetic neuralgia ⁽⁸⁾ AND
  • Pain duration less than 4 weeks, AND
  • Active antiviral therapy regimen or documented medical reason unable to tolerate
• Cancer pain, phantom limb pain, or nonsurgical ischemic limb pain ⁽²⁾ AND
  • Failure to respond to nonoperative conservative treatment pertinent to the diagnosis or a clearly documented medical reason the conservative treatment cannot be done
• The previous block resulted in at least 50% pain relief, significant documented functional improvement, or 50% reduction in PTSD symptoms for at least the duration of the anesthetic

NOTE: Up to 6 sympathetic blocks may be performed per 12 months.

Diagnostic Evaluation, Acute or Chronic Management of Sympathetically Maintained Pain Resulting From:

• Complex regional pain syndrome types I and II  ⁽⁹⁾ meeting Budapest criteria, AND
  • Failure to respond to functional restoration modalities which may include physical therapy, occupational therapy, or pain psychology modalities (e.g. rehabilitation strategies such as desensitization, range of motion, biofeedback, etc) or clearly documented medical reason the patient is unable to participate
  • Active participation in ongoing functional restoration or a clearly documented medical reason the treatment cannot be done⁽²⁾
• The previous block resulted in at least 50% relief or significant documented functional improvement for at least the duration of the anesthetic

NOTE: During the initial treatment phase, a total of 6 blocks may be performed within the first 12 weeks. Following the initial treatment phase, a maximum of 4 sympathetic nerve blocks may be performed in a 12-month period

General Limitations

• It has been at least one week since the prior injection in the same or different region
• Bilateral thoracic or lumbar sympathetic blocks will not be performed on the same day
• Imaging modalities do not include ultrasound guidance

Contraindications

• Patient refusal
• Local or systemic infection
• Coagulopathy, hypotension or recent myocardial infarction
• Contralateral pneumothorax
• Allergy to anesthetic medication

Indications for Celiac Plexus Block

Applies to the upper abdomen ⁽⁴⁾

For The Diagnostic Evaluation of Sympathetically Maintained Visceral Pain

• Upper abdominal pain associated with malignancy ⁽⁹⁾
  • Conservative treatment is not required
• Up to two diagnostic blocks may be performed in the initial diagnostic phase for a planned neurolysis procedure

For the Acute or Chronic Management of Sympathetically Maintained Visceral Pain Resulting From:

• Acute pancreatitis, OR
• Chronic, relapsing pancreatitis ⁽²⁾ AND
  • Failure to respond to nonoperative conservative treatment pertinent to the diagnosis or a clearly documented medical reason the conservative treatment cannot be done
• If the first injection is unsuccessful, a second initial injection may be performed in the initial phase for a maximum of 2 injections.
• After the initial phase, a therapeutic block may be performed every 3 months in a 12-month period
• The previous block resulted in at least 50% relief or significant documented functional improvement for at least the duration of the anesthetic
• Each therapeutic block resulted in at least 50% relief for a duration of 3 months

General Limitations

• At least one week between diagnostic blocks or injections performed in the initial phase

Contraindications

• Patient refusal
• Local or systemic infection
• Coagulopathy, hypotension or recent myocardial infarction
• Contralateral pneumothorax
• Allergy to anesthetic medication
• Abnormal anatomy

Indications for Superior Hypogastric Block

Applies to the pelvic and rectal regions ⁽⁴⁾

For The Diagnostic Evaluation of Sympathetically Maintained Visceral Pain

• Pelvic or rectal pain associated with malignancy
  • Conservative treatment is not required
• Up to two diagnostic blocks may be performed in the initial diagnostic phase for a planned neurolysis procedure

For the Acute or Chronic Management of Sympathetically Maintained Visceral Pain Resulting From:

• Chronic noncancer pain of pelvic and rectal viscera ⁽¹⁰⁾ AND
  • Failure to respond to nonoperative conservative treatment pertinent to the diagnosis or a clearly documented medical reason the conservative treatment cannot be done
• If the first injection is unsuccessful, a second initial injection may be performed in the initial phase for a maximum of 2 injections.
• After the initial phase, a therapeutic block may be performed every 3 months in a 12-month period
• The previous block resulted in at least 50% relief or significant documented functional improvement for at least the duration of the anesthetic
• Each therapeutic block resulted in at least 50% relief for a duration of 3 months

General Limitations

• At least one week between diagnostic blocks or injections performed in the initial phase
• Imaging modalities do not include ultrasound guidance

Contraindications

• Patient refusal
• Local or systemic infection
• Coagulopathy, hypotension or recent myocardial infarction
• Allergy to anesthetic medication
• Abnormal anatomy

Exclusions

These requests are excluded from consideration under this guideline;

• Sphenopalatine ganglion block
• Ganglion impar block
• Other parasympathetic ganglion blocks
• Inferior hypogastric block

References

1. Aman M M, Mahmoud A, Deer T, Sayed D, Hagedorn J M et al. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. Journal of pain research. 2021; 14: 2139-2164.

2. Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine*. Anesthesiology. 2010; 112: 810 - 833. 10.1097/ALN.0b013e3181c43103.

3. Li J, Szabova A. Ultrasound-Guided Nerve Blocks in the Head and Neck for Chronic Pain Management: The Anatomy, Sonoanatomy, and Procedure. Pain Physician. Dec 2021; 24: 533-548.

4. Doroshenko M, Turkot O, Horn D. Sympathetic Nerve Block. StatPearls. August 16, 2021; 2022:

5. Makharita M, Amr Y, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician. Nov-Dec 2012; 15: 467-74.

6. Yucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol. Dec 2009; 10: 179-83. 10.1007/s10195-009-0071-5.

7. Datta R, Agrawal J, Sharma A, Rathore V, Datta S. A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body. Journal of Anaesthesiology Clinical Pharmacology. 2017; 33: https://journals.lww.com/joacp/fulltext/2017/33040/a_study_of_the_efficacy_of_stellate_ganglion.22.aspx.

8. Bagaphou T, Santonastaso D, Gargaglia E, Norgiolini L, Tiburzi C et al. Ultrasound Guided Continuous Sciatic Nerve Block for Acute Herpetic Neuralgia. Case Rep Anesthesiol. 2019; 2019: 7948282. 10.1155/2019/7948282.

9. Gunduz O, Kenis-Coskun O. Ganglion blocks as a treatment of pain: current perspectives. Journal of pain research. 2017; 10: 2815-2826.

10. Rocha A, Plancarte R, Nataren R, Carrera I, Pacheco V. Effectiveness of Superior Hypogastric Plexus Neurolysis for Pelvic Cancer Pain. Pain physician. 2020; 23: 203-208.

Coding Section

Code	Number	Description
CPT	64510	Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
	64517	Injection, anesthetic agent; superior hypogastric plexus
	64520	Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
	64530	Injection, anesthetic agent; celiac plexus, without or without radiologic monitoring

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2026 Forward

06/01/2026

New Policy