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Date Printed: August 23, 2017: 01:40 PM

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Subject: Neurolysis

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This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

Neurolysis, also called neuroablation, destroys nerve tissue to help relieve pain. In this procedure, your doctor uses heat or chemicals to destroy the nerves. Three basic forms of neurolysis are used at this time.

Percutaneous Radiofrequency Neurolysis

This form of neurolysis may provide long-term neck and back pain relief. Typically, your doctor will first diagnose you using a treatment called a medial branch block. Your doctor will inject a local anesthetic near the two small nerves in the facet joints between the bones in your spine. If your pain improves by 50% or more, your doctor may diagnose you with facet joint pain.

After you are properly diagnosed, your doctor may treat you with Percutaneous Radiofrequency Neurolysis. First, a local anesthetic numbs the area to be treated. Using a special X-ray machine called a fluoroscope, your doctor will carefully guide a special needle to the nerves. This needle emits radio waves. These selectively destroy the nerve tissue causing the pain.

Cryoneurolysis

Cryoneurolysis is similar to Percutaneous Radiofrequency Neurolysis. Instead of radio waves, this method uses extreme cold to stop the nerve from sending pain signals.

Chemical Neurolysis

In this method, your doctor injects a chemical to destroy painful nerve tissues. Diluted alcohol is commonly used. Chemical neurolysis treats nerves outside the spine. This treatment is different from others, such as nerve blocks or local anesthetic injections, which numb the nerves but do not destroy them.

An example of disorders treated with chemical neurolysis includes Morton’s neuroma. This is an injury to the nerve between the toes, which causes thickening and pain. It commonly affects the nerves between the third and fourth toes. Symptoms include tingling, burning, numbness and pain.

Another example is plantar fasciitis. This is an inflammation of the fascia, a band of tissue in the bottom of the foot. Plantar fasciitis is painful and can make walking difficult.

Visit the Clinical View of this guideline for more information.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

 

Percutaneous Non-pulsed Radiofrequency Neurolysis under Fluoroscopic Guidance

When certain requirements are met, this procedure meets the definition of medical necessity for:

• pain in certain facet joints in the spine (cervical facet joints C3-4 and below, and lumbar facet joints)

All other forms of neurolysis to treat facet joint pain are considered experimental or investigational.

Radiofrequency neurolysis, laser neurolysis, or cryoneurolysis for all other conditions are considered experimental or investigational. Published clinical evidence does not support using these procedures for these locations.

After successful radiofrequency neurolysis, repeating a diagnostic medial branch block at the same location in the spine is not medically necessary.

Chemical neurolysis

When certain requirements are met, this procedure meets the definition of medical necessity for:

• Morton’s neuroma

• plantar fasciitis

• other neuritis of the foot

All other forms of neurolysis to treat conditions of the foot are considered experimental or investigational.

Visit the Clinical View of this guideline for specific coverage information.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: August 23, 2017: 01:40 PM