CMM-209~Regional Sympathetic Blocks

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1 MedSolutions, Inc. Clinical Decision Support Tool Diagnostic Strategies This tool addresses common symptoms and symptom complexes. Requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or patient s Primary Care Physician (PCP) may provide additional insight. COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES 2014 MedSolutions, Inc. CMM-209~Regional Sympathetic Blocks MedSolutions, Inc. Clinical Decision Support Tool Common symptoms and symptom complexes are addressed by this tool. Requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician may provide additional insight. CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein MedSolutions, Inc. Comprehensive Musculoskeletal Management Guidelines

2 COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM-209~Regional Sympathetic Blocks CMM-209 Regional Sympathetic Blocks Definitions General Guidelines Indications and Non-Indications Procedure (CPT ) Codes References 5 V 1.0 Regional Sympathetic Blocks RETURN Page 2 of 8

3 COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM Definitions Regional sympathetic blocks (Stellate Ganglion Blocks and Lumbar Sympathetic Blocks) refer to the injection of local anesthetic along the sympathetic ganglia of the anterolateral aspect of the spinal column under fluoroscopy to reduce sympathetic nervous system activity related to the affected limb. Complex regional pain syndrome 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 criterion for CRPS are as follows: o Continuing pain that is disproportionate to any inciting event o Must report at least one (1) of the symptoms in the following categories: Sensory: reports of hyperesthesia Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry Sudomotor/edema: reports of edema and/or sweating changes and/or sweating asymmetry Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin). o Must display at least one (1) of the signs in the following categories: Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch) Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) V 1.0 Regional Sympathetic Blocks RETURN Page 3 of 8

4 CMM General Guidelines The determination of medical necessity for the use of regional sympathetic blocks (Stellate Ganglion Blocks and Lumbar Sympathetic Chain Blocks) is always made on a case-by-case basis. Regional sympathetic blocks should be performed using fluoroscopy. Performance of regional sympathetic blocks without the use of fluoroscopic guidance is considered not medically necessary. CMM Indications and Non-Indications The performance of a diagnostic regional sympathetic block may be considered medically necessary for a patient who has been diagnosed with complex regional pain syndrome. A positive response is considered when there is at least 50% reduction in the patient s pain and improvement in function for the duration of the local anesthetic used. If less than 50% improvement is noted for the duration of the local anesthetic, further blocks may be considered not medically necessary. When performing repeat regional sympathetic blocks, a trial of up to three (3) additional blocks should be performed in the first two (2) weeks of treatment following the initial diagnostic injection. Continuation of the therapeutic blocks, up to a total of six (6) therapeutic blocks, should only be undertaken if there is documented evidence of pain reduction, decreased use of pain medication, increased functional abilities (including, but not limited to range of motion, strength, and use of the extremity in activities of daily living), or an increased tolerance to touch (decreased allodynia) during the rehabilitation program. The additional blocks should be performed at a one (1) time per week frequency. Based on the fact that there is no quality evidence that regional sympathetic blocks (Stellate Ganglion Blocks and Lumbar Sympathetic Chain Blocks) as an isolated treatment alter the long term outcome of CRPS, all regional sympathetic blocks in recalcitrant cases of CRPS should be performed in those patients who may benefit the from block to facilitate involvement and advancement in an active rehabilitation/functional restoration program. Regional sympathetic blocks which are performed in patients who are not capable or who are not actively involved in active rehabilitation program may be considered not medically necessary. V 1.0 Regional Sympathetic Blocks RETURN Page 4 of 8

5 CMM Procedure (CPT ) Codes This guideline 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. Preauthorization requirements vary by individual payor. CPT Code Description/Definition Injection, anesthetic agent; stellate ganglion(cervical sympathetic) 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 the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. CMM References 1. Ackerman W. Zhang J. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome.[see comment]. Southern Medical Journal. 99(10):1084-8, 2006 Oct. 2. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed Accessed 12/1/ American Medical Association. Current Procedural Terminology Professional Edition. 4. Baron R, Maier C. Reflex sympathetic dystrophy: skin blood flow, sympathetic vasoconstrictor reflexes and pain before and after surgical sympathectomy. Pain 1996; 67: Boas R. Sympathetic nerve blocks: in search of a role. Reg Anesth Pain Med. 1998;23: Bonelli S, Conoscente F, Movilia P, et al. Regional intravenous guanethidine vs. stellate ganglion block in reflex sympathetic dystrophies: double-blind study. Anesth Analg. 1992;74: Bruehl S, Carlson C. Predisposing psychological factors in the development of reflex sympathetic dystrophy: A review of the empirical evidence. Clin J Pain 1992; 8: Bruehl S, Harden R, Galer B, et al. External validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. Pain 1999; 81: Bruehl S, Lubenow T, Nath H, Ivankovich O. Validation of thermography in the diagnosis of reflex sympathetic dystrophy. Clin J Pain 1996; 12: Calvillo O, Racz G, Didie J, Smith K. Neuroaugmentation in the treatment of complex regional pain syndrome of the upper extremity. Acta Orthopaedica Belgica. 1998;64: Carlson L, Watson H. Treatment of reflex sympathetic dystrophy using the stress-loading program. J Hand Ther 1988; 1: Cepeda M, Carr D, Lau J. Local anesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev Oct 19;4:CD 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: 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. 147(7):505-14, 2007 Oct 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 Pain V 1.0 Regional Sympathetic Blocks RETURN Page 5 of 8

6 Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine. 147(7): , 2007 Oct 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. 147(7):478-91, 2007 Oct Chou R. Using evidence in pain practice: Part I: Assessing quality of systematic reviews and clinical practice guidelines. Pain Medicine. 9(5):518-30, 2008 Jul-Aug. 18. Cohen M, Quintner J. Fibromyalgia syndrome, a problem of tautology. Lancet 1993; 342: Cooper D, DeLee J, Ramamurthy S. Reflex sympathetic dystrophy of the knee. Treatment using continuous epidural anesthesia. J Bone Joint Surg Am. 1989;71: Crombez G, Vervaet L, Lysens R, et al. Avoidance and confrontation of painful, back straining movements in chronic back pain patients. Behav Modif 1998; 22: DuPen S, Peterson D, Williams A, Bogostan A. Infection during chronic catheter epidural catheterization: diagnosis and treatment. Anesthesiology. 1990;73: Evans J. Sympathectomy for reflex sympathetic dystrophy: report of 29 cases. JAMA. 1946;132: Forouzanfar T, Köke A, van Kleef M, Weber W. Treatment of complex regional pain syndrome type I. Eur J Pain. 2002;6: Furlan A, Mailis A, Papagapiou M. Are we paying a high price for surgical sympathectomy? A systematic literature review of late complications. J Pain 2000; 1: Galer B, Bruehl S, Harden R. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. Clin J Pain 1998; 14: Harden R, Bruehl S, Galer B, et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain 1999; 83: Harden R, Bruehl S, Stanton-Hicks M, Wilson P. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med May-Jun;8(4): Hartrick C, Kovan J, Naismith P. Outcome prediction following sympathetic block for complex regional pain syndrome. Pain Pract. 2004;4: Janig W, Baron R. Complex regional pain syndrome: mystery explained? Lancet Neurol. 2003;2: Janig W, Habler H. Sympathetic nervous system: contribution to chronic pain. Prog Brain Res. 2000;129: Kingery W. A critical review of controlled clinical trials for peripheral neuropathic and complex regional pain syndromes. Pain 1997; 73: Konig H, Christiaans C, Overdijk G, Mackie D. Cervical epidural blockade and reflex sympathetic dystrophy. Pain Clinic. 1995;8: Kori SH Miller R, Todd D. Kinesiophobia: a new view of chronic pain behavior. Pain Manag 1990; Kumar K, Nath R, Toth C. Spinal cord stimulation is effective in the management of reflex sympathetic dystrophy. Neurosurgery. 1997;40: Lee G, Weeks P. The role of bone scintigraphy in diagnosing reflex sympathetic dystrophy. J Hand Surg 1995; 20A: 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: Lynch M. Psychological aspects of reflex sympathetic dystrophy: a review of the adult and paediatric literature. Pain 1992; 49: V 1.0 Regional Sympathetic Blocks RETURN Page 6 of 8

7 38. Malmqvist E, Bengtsson M, Sorensen J. Efficacy of stellate ganglion block: a clinical study with bupivacaine. Reg Anesth. 1992;17: McCracken L, Gross R, Sorg P, Edmands T. Prediction of pain in patients with chronic low back pain: effects of inaccurate prediction and pain-related anxiety. Behav Res Ther 1993; 31: Oerlemans H. Oostendorp R. de Boo T. et al. Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I. Archives of Physical Medicine & Rehabilitation. 81(1):49-56, 2000 Jan. 41. 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. 18(8):653-8, 2004 Dec. 42. 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 Dec 7: 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: Price D, Bennett G, Rafii A. Psychophysiological observations on patients with neuropathic pain relieved by sympathetic block. Pain 1989; 36: Price D, Long S, Wilsey B, Rafii A. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain. 1998;14: Raj P, Montgomery S, Nettles D, Jenkins M. Infraclavicular brachial plexus block a new approach. Anesth Analg. 1973;52: Rauck R, Eisenach J, Jackson K, et al. Epidural clonidine for refractory reflex sympathetic dystrophy. Anesthesiology. 1993;79: 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: Schwartzman R, Kerrigan J. The movement disorder of reflex sympathetic dystrophy. Neurology 1990; 40: 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: 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: 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; Stanton-Hicks M. In: Wakefield CA, Bajwa JH. Principles and Practice of Pain Medicine. 2 nd ed Stanton-Hicks M, Baron R, et al. Consensus report: complex regional pain syndromes: guidelines for therapy. Clin J Pain 1998; 14: Stanton-Hicks M, Burton A, Bruehl S, et al. An updated interdisciplinary clinical pathway for CRPS: report of an expert panel. Pain Practice March; 84(3):S4-S Stanton-Hicks M. Complex regional pain syndrome. Anesthesiol Clin North America. 2003;21: Stanton-Hicks M. Complex regional pain syndrome: manifestations and the role of neurostimulation in its management. J Pain Symptom Manage Apr;31(4 Suppl):S20-4. V 1.0 Regional Sympathetic Blocks RETURN Page 7 of 8

8 58. Stanton-Hicks M, Janig W, Hassenbusch S, et al. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995; 63: 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: 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: van der Laan L, Veldman P, Goris J. Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, myoclonus. Arch Phys Med Rehabil 1998; 79: Varrassi G, Paladini A, Marinangeli F, Racz G. Neural modulation by blocks and infusions. Pain Pract. 2006;6: Verdugo R, Ochoa JL. Sympathetically maintained pain I. Phentolamine block questions the concept. Neurology. 1994;44: Vlaeyen J, Kole-Snijders A, Rotteveel A, et al. The role of fear of movement/(re)injury in pain disability. J Occup Rehabil 1995; 5: 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): Watson H, Carlson L. Treatment of reflex sympathetic dystrophy of the hand with an active stress loading program. J Hand Surg 1987; 12A: Werner R, Davidoff G, Jackson D, et al. Factors affecting the sensitivity and specificity of the threephase technetium bone scan in the diagnosis of reflex sympathetic dystrophy syndrome in the upper extremity. J Hand Surg 1989; 14A: Workloss Data Institute. Official Disability Guidelines V 1.0 Regional Sympathetic Blocks RETURN Page 8 of 8

REGIONAL SYMPATHETIC BLOCKS

REGIONAL SYMPATHETIC BLOCKS evicore healthcare. Clinical Decision Support Tool Diagnostic Strategies This tool addresses common symptoms and symptom complexes. Imaging requests for patients with atypical symptoms or clinical presentations