MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Insulin Infusion Pump-MP-MM-1316 06/01/2025 Kentucky inactive as of 01/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 I. References ………………………….. ………………………….. ………………………….. ……………………. 5 Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectInsulin Infusion Pump B. Background38.4 million people (11. 6% of the population) in the United States have diabetes mellitus (DM), not including the estimated 8.5 million adults who are undiagnosed. Approximately 5 to 10% of individuals with diabetes have type 1 (T1D) , while type 2 (T2D) accounts for the remaining 90 to 95% of cases. The incidence of both T1D and T2D in children and adolescents has significantly increased, according to the Centers for Disease Control (CDC) National Diabetes Statistic Report. Some of the unique challenges associated with caring for children and adolescents include the patients size, de velopmenta l concerns, and inability to communicate symptoms of hypoglycemia. Health care resources spent on diabetes are considered to be higher than all other health conditions. Immediate impacts on both physical and mental well-being are common with both severe hy poglycemia and extreme hyperglycemia. Patients with diabetes need to be closely monitored. When blood glucose levels are poorly controlled, patients are at risk of complications, including heart disease, stroke, peripheral vascular disease, retinal damage, kidney disease, nerve damage, and imp otence. Patients should also be monitored for comorbidities that may not be presentduring the early stages of the disease but develop as the disease progresses, including hearing impairment, fatty liver disease, sleep apnea, periodontal disease, depressio n, anxiety, cognitive impairment, and fractures. Reasonable glycated hemoglobin (A1C) goals for diabetic patients should be customized for the individual patient, balancing established benefits with prevention of complications and risk of hypoglycemia. Goals vary depending on age, comorbidities, and the benefitsof intensive therapy. Patients with T1D while pregnant may require stricter control.Insulin therapy is the mainstay of treatment for T1D and T2D . External insulin pumps arean option for intensive insulin therapy designed to provide continuous subcutaneous insulin infusion (CSII) to improve glycemic control, meet basal insulin requirements, and supplement bolus insulin delivery to assist in mealti me insulin needs. The AmericanAssociation of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE), and American Diabetes Association (ADA) recommend CSII only in individuals with T1D and patients with T2D who are insulin dependent. Insulin absorption with CSII therapy appears to be less variable and may help members that have not been able to achieve optimum glycemic goals with multiple daily injections. The choice of insulin delivery via multiple daily injections or continuous subcutaneous delivery of a rapid – acting insulin preparation via a pump should be carefully considered and thoroughly explained to the member. Insulin pumps should only be used in patients who are motivat ed and knowledgeable in DM self-care and able to safely manage the device. Additionally, newer, sensor-augmented insulin pump systems are available with continuous glucose monitoring (CGM) integrated into the pump, which may reduce nocturnal hypoglycemia. Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 C. Definitions Dawn Phenomenon An observed increase in blood sugar levels that takes place in the early morning, often between 2am and 8am. Insulin Infusion Pump An external pump used to deliver insulin subcutaneously or through an intraperitoneal route in a controlled and programmed way in order to prevent acute metabolic complications of diabetes and obtain normal blood glucose levels. Moderately Increased Albuminuria Persistent urine albumin-to-creatinine ratio values between 30 and 300mg/gram creatinine. Previously called microalbuminuria, this is usually indicative of diabetic nephropathy (unless there is some other coexistent renal disease). Sensor-Augmented Insulin Pump System An insulin infusion pump equipped with a CGM sensor that uses the glucose readings taken by the CGM sensor to modify the amount of insulin infused . D. PolicyI. CareSource considers the use of external insulin infusion pumps medically necessary when ALL the following criteria are met: A. Documented diagnosis of one of the following: 1. T1D 2. T2D with insulin dependency B. Diabetic education, equipment, and supplies must be ordered in writing by a physician or other appropriately credentialed health care provider . C. The members provider and provider team have an expert level of experience in the management and support of members with insulin infusion pumps . D. Documentation that the patient has completed a comprehensive diabetes education program within the last 12 months by a certified, registered, or licensed provider with expertise in diabetes . E. The member or members caregiver must be knowledgeable in operating the device . F. The member has been on a maintenance program for at least 6 months involving at least 3 injections of insulin per day requiring frequent self-adjustments of insulin dosage . G. The member has performed glucose self-testing at least 4 times per day on average during the last month . H. The member is at high risk for preventable complications of diabetes, early signs of which include: 1. moderately increased albuminuria (eg, microalbuminuria) 2. persistent difficulty in controlling blood sugar levels despite compliance with an intensive multiple-injection regimen, as indicated in documented member log I. The member has at least one of the following symptoms or conditions: 1. A1 Cgreater than 7% 2. history of recurring hypoglycemia Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 3. wide fluctuations in blood glucose before mealtime4. dawn phenomenon frequently exceeding 200 mg/dl 5. history of severe glycemic excursions II. ExclusionsA. CareSource considers insulin pump therapy not medically necessary when any of the following apply: 1. Member has end-stage complications such as renal failure. 2. Neither the member nor anyone assisting the member is able to operate a pump or to perform frequent blood glucose monitoring. B. CareSource considers the following devices not medically necessary: 1. portable external insulin infusion pumps requested purely for convenience or member preference 2. surgically implanted infusion devices for systems 3. jet pressure devices 4. devices associated with chronic intermittent intravenous insulin therapy (CIIIT) 5. devices associated with pulsatile intravenous therapy (PIVIT) III. Device Replacement or RepairCareSource may cover the repair, adjustment, and/or replacement of purchased equipment, supplies, or appliances when approved. A. The repair, adjustment, or replacement of the purchased equipment, supply, or appliance is covered if: 1. The equipment, supply, or appliance is a covered service . 2. The continued use of the item is medically necessary . 3. There is reasonable justification for the repair, adjustment, or replacement. B. Replacement of a functioning device just because the warranty has expired is not considered medically necessary. C. Replacement of purchased equipment, supplies or appliances may be covered if: 1. The equipment, supply , or appliance is worn out or no longer functions. 2. Repair is not possible or would equal or exceed the cost of replacement. An assessment by a rehabilitation equipment specialist or vendor should be done to estimate the cost of repair. 3. Members needs have changed, and the current equipment is no longer usable due to weight gain, rapid growth, or deterioration of function, etc. 4. The equipment, supply, or allowance is damaged and cannot be repaired. 5. Benefits for repairs and replacement do not include: a. repair and replacement due to misuse, malicious breakage, or gross neglect b. replacement of lost or stolen items E. State-Specific InformationA. Georg ia marketplace. CareSource. Accessed February 13, 2025. www.caresource.com Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 B. Indiana marketplace. CareSource. Accessed February 13, 2025. www.caresource.comC. Kentucky marketplace. CareSource. Accessed February 13, 2025. www.caresource.com D. Ohio marketplace. CareSource. Accessed February 13, 2025. www.caresource.com E. West Virginia marketplace. CareSource. Accessed February 13, 2025. www.caresource.com F. Conditions of CoverageN/A G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/13/2022 New policy, replacing individual state policiesDate Revised 03/29/2023 03/13/202402/26/2025Annual review: updated references. Approved at Committee. Annual review: editorial changes, updated background, and updated references. Approved at Committee. Annual review : added other provider to D.I.B . Approved at Committee. Date Effective 06/01/2025 Date Archived I. References1. American Diabetes Association Professional Practice Committee. Diabetes technology: standards of care in diabetes 2024. Diabetes Care . 2024;47(Suppl 1):S126-S126-S144. doi.org/10.2337/dc24-S007 2. Blonde L, Umpieerez GE, Reddy SS, et al. American Association of Clinical Endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan 2022 update. Endocr Pract . 2022;28(10):923-1049. doi:10.1016/j.eprac.2022.08.002 3. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. Reviewed May 15, 2024. Accessed February 13, 2025 . www.cdc.gov 4. Glycemic targets: standards of medical care in diabetes 202 3. Diabetes Care . 202 3;46(Suppl 1):S 97-S110 . doi:10.2337/dc23-S006 5. Heinemann L, Fleming GA, Petrie JR, et al. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care . 2015;38(4):716-722. doi:10.2337/dc15-0168 Insulin Infusion Pump-MP-MM-1316Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 6. Levitsky L L, Misra M . Overview of the management of type 1 diabetes mellitus in children and adolescents. UpToDate. Updated November 15, 2023. Accessed February 13, 2025 . www.uptodate.com 7. Levitsky L L, Misra M. Hypoglycemia in children and adolescents with type 1 diabetes mellitus. UpToDate. Updated December 30, 2022. Accessed February 13, 2025 . www.uptodate.com 8. Levitsky L L, Misra M. Insulin therapy for children and adolescents with type 1 diabetes mellitus. UpToDate. Updated October 23, 2023. Accessed February 13, 2025 . www.uptodate.com 9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes – 202 3. Diabetes Care . 202 3;46(Suppl 1):S1 40-S157 . doi:10.2337/dc23-S009 10. Weinstock RS. Management of blood glucose in adults with type 1 diabetes mellitus. UpToDate. Updated January 2, 2024. Accessed February 13, 2025 . www.uptodate.com 11. Wexler DJ. Overview of general medical care in nonpregnant adults with diabetes mellitus. UpToDate. Updated August 30 , 2024. Accessed February 13, 2025 . uptodate.com Independent med ical review April 2020
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401 06/01/2025 Kentucky Inactive 01/01/2026 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 4 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 5 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 I. References ………………………….. ………………………….. ………………………….. …………………….. 5 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectPeripheral Nerve Blocks for Treatment of Pain B. BackgroundPeripheral nerve blocks are injections of medication into a specific area of the body where nerves cause pain to a specific organ or body region. Nerve blocks cause the temporary interruption of impulse conduction in peripheral nerves or nerve trunks and may or may not contain a steroid, which can be used to treat pain . Various areas of pain require different types of nerve blocks that can be administered in numerous parts of the body with some of the most common blocks being sympathetic, peripheral, and oc cipital. Sacroiliac and facet joint interventions, epidural steroid injections, and trigger point injections are addressed in other policies.C. Definitions Acute Pain Pain that lasts less than 4 weeks. Ambulatory Surgery Surgery performed in a hospital-based or freestanding ambulatory surgery center (ASC) with patient discharge the same day. Chronic Pain Pain lasting more than 3 months, which is considered beyond normal healing time. Conservative Therapy A multimodality plan including both active and inactive conservative therapies . o Active Conservative Therapies Actions or activit ies that strengthen muscle groups and target key spinal structures, including physical therapy, occupational therapy, a physician-supervised home exercise program (HEP), and/or chiropractic care. HEP A 6-week program requiring an exercise prescription , and/or plan and a follow-up documented in the medical record after completion, or documentation of the inability to complete due to a stated physical reason (ie, increased pain, inability to physically perform exercises). Patient inconvenience and/ or noncompliance without explanation does not constitute inability to complete . o Inactive Conservative Therapies Passive activities by the member that aid in treating symptoms with pain , including rest, ice, heat, medical devices, acupuncture , TENS u se , and/or pharmacotherapy (prescription or over the counter [eg, NSAIDS, acetaminophen]) . Transcutaneous Electrical Nerve Stimulator ( TENS ) A device that utilizes electrical current directed through electrodes placed on the surface of the skin to decrease the patients perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulat e the release of endorphins . Use, frequency, duration, and start dates must be documented in the medical record . Emergent Medically necessary care which is immediately needed to preserve life , prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of a patient in serious jeopardy. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 Low-Risk Procedu re Procedures associated with minimal physiologic effect and exclude any intrathoracic, intra-abdominal, vascular, or orthopedic procedures. Sub-Acute Pain Pain lasting between 4 and 12 weeks. D. PolicyI. CareSource considers peripheral nerve blocks (PNB) , single injection, medically necessary when appropriate documentation for the treatment of acute pain or chronic pain are included, only as part of an active component of a comprehensive pain management program. CareSource uses MCG Health guidelines to ad dress criteria for specific nerve blocks. Documentation must include indications that ALL the following criteria are met: A. Ambulatory or outpatient procedure that is not emergent, low risk, and requires no inpatient care for a preoperative disease or condition (eg, altered mental status, hypotension, hypoxemia, tachycardia) B. Acute, sub-acute or chronic, neuropathic or radicular pain, as indicated by ONE or more of the following: 1. Cancer-related pain 2. Complex Regional Pain Syndrome (CRPS) 3. Peripheral neuropathy with pain that limits activities of daily living, excluding diabetic neuropathy 4. Peripheral vascular disease with rest pain 5. Acute herpes zoster of face or neck and prevention of postherpetic neuralgia 6. Pancreatic pain, pelvic pain, or abdominal pain related to malignancy 7. Chronic, relapsing pancreatitis C. Symptoms poorly controlled by maximum medical therapy or intolerable side effects to such therapy D. Failure of non-invasive treatment(s) (eg, non-steroidal anti-inflammatory drugs (NSAIDs), exercise, physical therapy, spinal manipulation therapy) E. No coagulopathy or thrombocytopenia F. No infection at or underlying the injection site II. Acute or Sub-Acute PainPNB may provide means of analgesia for acute pain in the following (not an all – inclusive list): A. Patients at risk of respiratory depression related to systemic or neuraxial opioids (eg, obstructive sleep apnea, severe obesity, underlying pulmonary disease, advanced age). B. Patients with another indication to minimize opioid use (eg, chronic opioid use, intolerance to opioids). C. Patients with acute, severe pain poorly managed with systemic medication. D. Patients who cannot tolerate chiropractic or other physical and/or manipulative therapies. Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 III. Chronic PainCareSource considers PNB , single injection, medically necessary when appropriate documentation for the treatment of chronic pain is included, only as part of an active component of a comprehensive pain management program when the following criteria are met: A. Failure of conservative therapy, as evidenced by ALL the following: 1. Documentation in the medical record of at least 6 weeks of active conservative therapy within the past 6 months OR inability to complete active conservative therapy due to contraindication, increased pain, or intolerance . 2. Documentation in the medical record of at least 6 weeks inactive conservative therapy within the past 6 months . B. Insufficient evidence support s the use of PNB for chronic pain: 1. Genicular nerve or branches for chronic knee pain 2. Cluneal nerve injections or blocks for chronic low back pain or pelvic pain 3. Pudendal blocks for chronic pelvic pain conditions. IV. Peripheral Radiofrequency Ablation (RFA) or NeurotomyRadiofrequency ablation and/or neurotomy are considered experimental and investigational, or unproven for any indication, including but not limited to the treatment of acute or chronic pain due to insufficient evidence of efficacy in the peer reviewed literature. V. Limitations and ExclusionsA. A member can receive a maximum of 6 injections per area and anatomical side in a calendar year . B. Up to 2 anatomic sites (eg, specific nerve, plexus, or branch as defined by CPT code description) may be injected at any one session. C. Nerve blocks used as part of a surgical procedure or other medical procedure are not separately reimbursable but an inclusive component of that procedure. These injections will not be compensated separately or unbundled for coverage. D. Any procedure submitted for payment with an incorrect CPT code or description will be denied. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. If requesting a block to a specific part of the body, coding to the highest level of specificity should be used. E. Exclusion s 1. Treatment of peripheral neuropathy due to diabetes. 2. Use of nerve blocks with or without use of electrostimulation for treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. Medical management using systemic medications is clinically indicated for the treatment of these conditions. E. State-Specific InformationN/A Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 F. Conditions of CoverageInterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by healthcare providers within their scope of practice who are qualified to deliver these health services . G. Related Policies/RulesEpidural Steroid Injections Facet Joint Interventions Sacroiliac Joint Procedures Trigger Point Injections H. Review/Revision HistoryDATE ACTIONDate Issued 05/01/2023Date Revised 02/28/2024 07/03/2024 02/26/2025 Annual review-editorial changes ; Approved at Committee Revision – clarified limitations in D.V.A. Approved at Committee. Annual review, references updated. Approved at Committee. Date Effective 06/01/2025 Date Archived I. References1. Ailani J, Burch RC, Robbins MS; American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache . 2021;61(7):1021-1039. doi:10.1111/head.14153 2. Allen SM, Mookadam F, Cha SS, et al. Greater occipital nerve block for acute treatment of migraine headache: a large retrospective cohort study. JAm Board Fam Med . 2018;31(2):211-218. doi:10.3122/jabfm.2018.02.170188 3. American Headache Society. AHS consensus statement: The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache . 2019;59(1):1-18. doi:10.1111/head.13456 4. Antolak S, Antolak C, Lendway L. Measuring the quality of pudendal nerve perineural injections. Pain Physician . 2016;19:299-306. Accessed February 9, 202 5. www.pubmed.ncbi.nlm.nih.gov 5. Caponnetto V, Ornello R, Frattale I, et al. Efficacy and safety of greater occipital nerve block for the treatment of cervicogenic headache: a systematic review. Expert Rev Neurotherapeutics . 2021; 21(5):591-597. doi:10.1080/14737175.2021.1903320 6. Chang A, Dua A, Singh K, White BA. Peripheral nerve blocks. StatPearls . StatPearls Publishing; 2024. Accessed February 9, 2025 . www.ncbi.nlm.nih.gov 7. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. UpToDate. Updated May 15, 2024. Accessed February 9, 2025. www.uptodate.com 8. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 9. Evidence Analysis Research Brief: Pudendal Nerve Decompression Surgery for Treatment of Pudendal Neuralgia. Hayes; 2022. Accessed February 9, 2025. www.evidence.hayesinc.com10. Evidence Analysis Research Brief: Radiofrequency Ablation of Cluneal Nerve for Treatment of Chronic Low Back Pain. Hayes; 2023. Accessed February 9, 2025. 11. Evolving Evidence Review: Middle Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2022. Reviewed April 4, 2023. Accessed February 9, 2025. www.evidence.hayesinc.com 12. Evolving Evidence Review: Superior Cluneal Nerve Block for Treatment of Low Back Pain. Hayes; 2021. Reviewed December 18, 2024. Accessed February 9, 2025. www.evidence.hayesinc.com 13. Frank FT, Sawsan A. Chronic pelvic pain in adult females: treatment. UpToDate. Updated August 16, 2024. Accessed February 9, 2025. www.uptodate.com 14. Garza I. Occipital neuralgia. UpToDate. Updated December 17, 2024. Accessed February 9, 2025. www.uptodate.com 15. Garza I, Schwedt TJ. Chronic migraine. UpToDate. Updated October 3, 2024. Accessed February 9, 202 5. www.uptodate.com 16. Gautam S, Gupta N, Khuba S, et al. Evaluation of the efficacy of superior cluneal nerve block in low back pain: a prospective observational study. JBodyw Mov Ther . 2022;30:221-225. doi:10.1016/j.jbmt.2022.03.001 17. Headaches in Over 12s: Diagnosis and Management . National Institute for Excellence; 2012. CG150. Updated December 17, 2021. Accessed February 9, 2025. www.nice.org 18. Health Technology Assessment: Genicular Nerve Block for the Treatment of Knee Osteoarthritis. Hayes; 2023. Reviewed December 19, 2024. Accessed February 9, 2025 . www.evidence.hayesinc.com 19. Health Technology Assessment: Greater Occipital Nerve Blocks for Treatment of Migraine. Hayes; 2019. Reviewed October 10, 2022. Accessed February 9, 202 5. www.evidence.hayesinc.com 20. Health Technology Assessment: Local Injection Therapy for Cervicogenic Headache and Occipital Neuralgia. Hayes; 2017. Reviewed November 15, 2021. Accessed February 9, 2025. www.evidence.hayesinc.com 21. Health Technology Assessment: Peripheral Nerve Field Stimulation for Treatment of Chronic Low Back Pain. Hayes; 2021. Reviewed April 17, 2024. Accessed February 9, 2025 . www.evidence.hayesinc.com 22. Hui J, Seko K, Shrikhande G, et al. A novel, nonopiod-based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound-guided nerve hydrodissection and pelvic floor musculature trigger point injections. Neurourol Urodyn . 2020;39(2):658-664. doi:10.1002/nau.24242 23. Inan L, Inan N, Unal-Artik H, et al. Greater occipital nerve block in migraine prophylaxis: narrative review. Cephalalgia . 2019;39:908-920. doi:10.1177/0333102418821669 24. Isu T, Kim K, Morimoto D, Iwamoto N. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine . 2018;15(1):25-32. doi:10.14245/ns.1836024.012 Peripheral Nerve Blocks for Treatment of Pain-MP-MM-1401Effective Dat e: 06/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 25. Jeng C, Rosenblatt M. Overview of peripheral nerve blocks. UpToDate. UpdatedJanuary 10, 2024. Accessed February 9, 2025. www.uptodate.com 26. Matsumoto J, Isu T, Kim K, et al. Middle cluneal nerve entrapment mimics sacroiliac joint pain. Acta Neurochir (Wien) . 2019;161(4):657-661. doi:10.1007/s00701-019 – 03861-0 27. Mustafa A, Brooks B, Leishear K, et al. A novel treatment approach for women with chronic pelvic pain syndrome leading to increased pelvic functionality. JWomens Health Gyn . 2020;7:1-10. doi:10.17303/jwhg.2020.7.402 28. Nielsen TD, Moriggl B, Barckman J, et al. Randomized trial of ultrasound-guided superior cluneal nerve block. Reg Anesth Pain Med . 2019;44:772-780. doi:10.1136/rapm-2018-100174 29. Ornello R, Lambru G, Caponnetto V, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta – analysis. Expert Rev Neurotherapeutics . 2020;20(11):1157-1167. doi:10.1080/14737175.2020.1809379 30. Pilitsis JG, Khazen O. Occipital neuralgia. American Academy of Neurological Surgeons (AANS). Accessed February 9, 2025. www.aans.org 31. Plavnik K, Tenaglia A, Hill C, et al. A novel, non-opioid treatment for chronic pelvic pain in women with previously treated endometriosis utilizing pelvic-floor musculature trigger-point injections and peripheral nerve hydrodissection. PM R . 2020;12(7):655 – 662. doi:10.1002/pmrj.12258 32. 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(4):810-833. doi:10.1097/ALN.0b013e3181c43103 33. Shauly O, Gould DJ, Sahai-Srivastava S, et al. Greater occipital nerve block for the treatment of chronic migraine headaches: a systematic review and meta-analysis. Plast Reconstr Surg . 2019;144(4):943-952. doi:10.1097/PRS.0000006059 34. Tu FF, As-Sanie S. Chronic pelvic pain in adult females: evaluation. UpToDate. Updated August 16, 2024. Accessed February 9, 2025. www.uptodate.com 35. Watson JC. Cervicogenic headache. UpToDate. Updated March 12, 2024. Accessed February 9, 2025. www.uptodate.com 36. Wray JK, Dixon B, Przkora R. Radiofrequency ablation. StatPearls . StatPearls Publishing; 2025. Accessed February 9, 2025. www.ncbi.nlm.nih.gov
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