Clinical Policy Bulletin: Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments

Number: 0447 (Replaces CPB 550) Policy I. Aetna considers continuous epidural analgesia medically necessary for the treatment of members with intractable complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), when all of the following selection criteria are met: ■ Members have experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications); and ■ Members have failed a trial of physical therapy; and ■ Members have failed a trial of nerve blocks with local anesthetics and steroids. Aetna considers continuous epidural analgesia experimental and investigational for the treatment of CRPS when criteria are not met. II. Aetna considers sympathetic blocks (e.g., stellate ganglion block [cervical sympathetic block] and lumbar sympathetic block) medically necessary for the treatment of CRPS when conservative treatments, including analgesia and physical therapy, have failed. Up to three 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 three injections, additional injections are not considered medically necessary. Repeat sympathetic blocks for complex regional pain syndrome beyond the first three injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate. It is not considered medically necessary to repeat sympathetic blocks more frequently than once every 7 days. III. Aetna considers dorsal column stimulators medically necessary durable medical equipment for the management of CRPS if the member meets all of the criteria listed in CPB 0194-Dorsal Column Stimulation. IV. Aetna considers intravenous administration of guanethidine, ketamine (including "ketamine coma"-extended use of ketamine at anesthetic dosages), lidocaine or midazolam experimental and investigational for the treatment of CRPS, other types of chronic pain, and depression because their effectiveness for these indications has not been established. V. Aetna considers intrapleural analgesia experimental and investigational for the treatment of CRPS with chronic pain involving the thoracic dermatomes since there is a lack of scientific evidence to support its effectiveness for this indication. VI. Aetna considers neurolysis of the spinal accessory nerve experimental and investigational in the treatment of CRPS and post traumatic chronic pain syndrome because there is inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness. VII. Aetna consider the following approaches experimental and investigational for the treatment of CRPS because their effectiveness for this indication has not been …