Aetna · Clinical coverage policy

Aetna CRPS/RSD Treatments coverage criteria

Aetna CPB 0447 covers a narrow set of CRPS/RSD treatments: continuous epidural analgesia, sympathetic blocks (stellate ganglion or lumbar sympathetic), and dorsal column stimulators, all gated on documented failure of conservative therapy (typically 3+ months including physical therapy, and for epidural analgesia also failed nerve blocks). Sympathetic blocks are capped at 3 diagnostic/therapeutic injections unless part of a comprehensive pain management program and no more often than once every 7 days, and DCS additionally requires meeting all spinal-cord-stimulation criteria in CPB 0194; a large list of other pharmacologic, procedural, neuromodulation, and physical interventions (e.g., IV ketamine/lidocaine, intrathecal agents, IVIG, biologics, transcranial stimulation) is deemed experimental, investigational, or unproven.

Policy CPB 0447 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0447

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0447 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover CRPS/RSD Treatments (CPT 01996), and what gets it denied?

Path
Aetna CPB 0447 covers a narrow set of CRPS/RSD treatments: continuous epidural analgesia, sympathetic blocks (stellate ganglion or lumbar sympathetic), and dorsal column stimulators, all gated on documented failure of conservative therapy (typically 3+ months including physical therapy, and for epidural analgesia also failed nerve blocks). Sympathetic blocks are capped at 3 diagnostic/therapeutic injections unless part of a comprehensive pain management program and no more often than once every 7 days, and DCS additionally requires meeting all spinal-cord-stimulation criteria in CPB 0194; a large list of other pharmacologic, procedural, neuromodulation, and physical interventions (e.g., IV ketamine/lidocaine, intrathecal agents, IVIG, biologics, transcranial stimulation) is deemed experimental, investigational, or unproven. Coverage criteria include: Continuous epidural analgesia for the treatment of members with intractable CRPS/RSD is medically necessary when ALL of the following are met: (1) member has experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications); AND (2) member has failed a trial of physical therapy; AND (3) member has failed a trial of nerve blocks with local anesthetics and steroids; Sympathetic blocks (e.g., stellate ganglion block [cervical sympathetic block] and lumbar sympathetic block) for the diagnosis and treatment of sympathetically-maintained pain and/or CRPS are medically necessary when 3 months of conservative treatments, including analgesia and physical therapy (PT), have failed; Up to 3 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 3 injections, additional injections are NOT medically necessary); Repeat sympathetic blocks for CRPS beyond the first 3 injections are medically necessary ONLY when provided as part of a comprehensive pain management program, which includes PT, patient education, psychosocial support, and oral medications, where appropriate (and NOT more frequently than once every 7 days); Dorsal column stimulators (DCS) are medically necessary durable medical equipment (DME) for the management of CRPS when the member meets ALL of the criteria listed in CPB 0194 - Spinal Cord Stimulation. Applies to 12 codes: 01996, 62324, 62325, 62326, 62327, 64510, 64520, 64530, 63650, 63655, 63685, 63688.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Note: For clinical diagnostic criteria for complex regional pain syndrome, see Appendix for the Budapest Criteria.
Trap
Policy exclusions and limitations: Continuous epidural analgesia is experimental, investigational, or unproven for the treatment of CRPS when the medically-necessary criteria are NOT met; Additional sympathetic block injections beyond 3 are NOT medically necessary if the member experiences no pain relief after the first 3 injections; It is NOT medically necessary to repeat sympathetic blocks more frequently than once every 7 days; Experimental/investigational/unproven: Intravenous administration of guanethidine, ketamine (including 'ketamine coma') for CRPS; Experimental/investigational/unproven: Intravenous administration of lidocaine or midazolam for CRPS; Experimental/investigational/unproven: Intrapleural analgesia for CRPS with thoracic dermatomes involvement; Experimental/investigational/unproven: Neurolysis of the spinal accessory nerve; Experimental/investigational/unproven: Amputation; Experimental/investigational/unproven: Bier block; Experimental/investigational/unproven: Bio-Electro-Magnetic-Energy-Regulation (BEMER) magneto-therapy; Experimental/investigational/unproven: Bisphosphonates; Experimental/investigational/unproven: Botulinum toxin; Experimental/investigational/unproven: Bupivacaine brachial plexus block; Experimental/investigational/unproven: Combined dorsal root ganglion and dorsal column spinal cord stimulation; Experimental/investigational/unproven: Combined transcranial direct current stimulation and TENS; Experimental/investigational/unproven: Compression sleeve; Experimental/investigational/unproven: Electroconvulsive therapy; Experimental/investigational/unproven: Exergame therapy; Experimental/investigational/unproven: Free-flap surgery and vein wrapping; Experimental/investigational/unproven: Hypnosis; Experimental/investigational/unproven: Interleukin-1 receptor antagonist (anakinra, canakinumab, rilonacept, sarilumab, tocilizumab); Experimental/investigational/unproven: Intrathecal adenosine; Experimental/investigational/unproven: Intrathecal baclofen; Experimental/investigational/unproven: Intrathecal clonidine; Experimental/investigational/unproven: Intrathecal corticosteroid; Experimental/investigational/unproven: Intravenous immunoglobulin; Experimental/investigational/unproven: Intravenous magnesium; Experimental/investigational/unproven: Intravenous propofol infusion; Experimental/investigational/unproven: Ketamine metabolite (2R,6R)-hydroxynorketamine; Experimental/investigational/unproven: Low-dose naltrexone; Experimental/investigational/unproven: Metformin; Experimental/investigational/unproven: Movement representation techniques (action observation, mirror therapy, motor imagery); Experimental/investigational/unproven: Multi-site continuous peripheral nerve catheters; Experimental/investigational/unproven: Mycophenolate; Experimental/investigational/unproven: Neuroplasty; Experimental/investigational/unproven: Occlusal splint; Experimental/investigational/unproven: Oral memantine; Experimental/investigational/unproven: Percutaneous peripheral nerve stimulation (with/without ultrasound); Experimental/investigational/unproven: Prism adaptation treatment; Experimental/investigational/unproven: Pulsed light therapy; Experimental/investigational/unproven: Pulsed radiofrequency; Experimental/investigational/unproven: Radiofrequency sympathetic neurotomy; Experimental/investigational/unproven: Sanexas (electroanalgesia); Experimental/investigational/unproven: Sensory retraining; Experimental/investigational/unproven: Tadalafil; Experimental/investigational/unproven: Thalidomide; Experimental/investigational/unproven: Topical dimethyl sulfoxide; Experimental/investigational/unproven: Topical ketamine; Experimental/investigational/unproven: Transcranial direct current stimulation; Experimental/investigational/unproven: Transcranial magnetic stimulation; Experimental/investigational/unproven: Tumor necrosis factor-alpha antagonists (adalimumab, certolizumab, etanercept, golimumab, infliximab); Experimental/investigational/unproven: Virtual body swapping. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0447 — CRPS/RSD Treatments

Coverage criteria

  • Continuous epidural analgesia for the treatment of members with intractable CRPS/RSD is medically necessary when ALL of the following are met: (1) member has experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications); AND (2) member has failed a trial of physical therapy; AND (3) member has failed a trial of nerve blocks with local anesthetics and steroids
  • Sympathetic blocks (e.g., stellate ganglion block [cervical sympathetic block] and lumbar sympathetic block) for the diagnosis and treatment of sympathetically-maintained pain and/or CRPS are medically necessary when 3 months of conservative treatments, including analgesia and physical therapy (PT), have failed
  • Up to 3 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 3 injections, additional injections are NOT medically necessary)
  • Repeat sympathetic blocks for CRPS beyond the first 3 injections are medically necessary ONLY when provided as part of a comprehensive pain management program, which includes PT, patient education, psychosocial support, and oral medications, where appropriate (and NOT more frequently than once every 7 days)
  • Dorsal column stimulators (DCS) are medically necessary durable medical equipment (DME) for the management of CRPS when the member meets ALL of the criteria listed in CPB 0194 - Spinal Cord Stimulation

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Note: For clinical diagnostic criteria for complex regional pain syndrome, see Appendix for the Budapest Criteria

Frequently asked questions

When does Aetna cover CRPS/RSD Treatments (CPT 01996), and what gets it denied?
Aetna CPB 0447 covers a narrow set of CRPS/RSD treatments: continuous epidural analgesia, sympathetic blocks (stellate ganglion or lumbar sympathetic), and dorsal column stimulators, all gated on documented failure of conservative therapy (typically 3+ months including physical therapy, and for epidural analgesia also failed nerve blocks). Sympathetic blocks are capped at 3 diagnostic/therapeutic injections unless part of a comprehensive pain management program and no more often than once every 7 days, and DCS additionally requires meeting all spinal-cord-stimulation criteria in CPB 0194; a large list of other pharmacologic, procedural, neuromodulation, and physical interventions (e.g., IV ketamine/lidocaine, intrathecal agents, IVIG, biologics, transcranial stimulation) is deemed experimental, investigational, or unproven. Coverage criteria include: Continuous epidural analgesia for the treatment of members with intractable CRPS/RSD is medically necessary when ALL of the following are met: (1) member has experienced pain for more than 3 months despite conservative therapy (e.g., exercises, physical modalities and medications); AND (2) member has failed a trial of physical therapy; AND (3) member has failed a trial of nerve blocks with local anesthetics and steroids; Sympathetic blocks (e.g., stellate ganglion block [cervical sympathetic block] and lumbar sympathetic block) for the diagnosis and treatment of sympathetically-maintained pain and/or CRPS are medically necessary when 3 months of conservative treatments, including analgesia and physical therapy (PT), have failed; Up to 3 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 3 injections, additional injections are NOT medically necessary); Repeat sympathetic blocks for CRPS beyond the first 3 injections are medically necessary ONLY when provided as part of a comprehensive pain management program, which includes PT, patient education, psychosocial support, and oral medications, where appropriate (and NOT more frequently than once every 7 days); Dorsal column stimulators (DCS) are medically necessary durable medical equipment (DME) for the management of CRPS when the member meets ALL of the criteria listed in CPB 0194 - Spinal Cord Stimulation. Applies to 12 codes: 01996, 62324, 62325, 62326, 62327, 64510, 64520, 64530, 63650, 63655, 63685, 63688. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Note: For clinical diagnostic criteria for complex regional pain syndrome, see Appendix for the Budapest Criteria. Policy exclusions and limitations: Continuous epidural analgesia is experimental, investigational, or unproven for the treatment of CRPS when the medically-necessary criteria are NOT met; Additional sympathetic block injections beyond 3 are NOT medically necessary if the member experiences no pain relief after the first 3 injections; It is NOT medically necessary to repeat sympathetic blocks more frequently than once every 7 days; Experimental/investigational/unproven: Intravenous administration of guanethidine, ketamine (including 'ketamine coma') for CRPS; Experimental/investigational/unproven: Intravenous administration of lidocaine or midazolam for CRPS; Experimental/investigational/unproven: Intrapleural analgesia for CRPS with thoracic dermatomes involvement; Experimental/investigational/unproven: Neurolysis of the spinal accessory nerve; Experimental/investigational/unproven: Amputation; Experimental/investigational/unproven: Bier block; Experimental/investigational/unproven: Bio-Electro-Magnetic-Energy-Regulation (BEMER) magneto-therapy; Experimental/investigational/unproven: Bisphosphonates; Experimental/investigational/unproven: Botulinum toxin; Experimental/investigational/unproven: Bupivacaine brachial plexus block; Experimental/investigational/unproven: Combined dorsal root ganglion and dorsal column spinal cord stimulation; Experimental/investigational/unproven: Combined transcranial direct current stimulation and TENS; Experimental/investigational/unproven: Compression sleeve; Experimental/investigational/unproven: Electroconvulsive therapy; Experimental/investigational/unproven: Exergame therapy; Experimental/investigational/unproven: Free-flap surgery and vein wrapping; Experimental/investigational/unproven: Hypnosis; Experimental/investigational/unproven: Interleukin-1 receptor antagonist (anakinra, canakinumab, rilonacept, sarilumab, tocilizumab); Experimental/investigational/unproven: Intrathecal adenosine; Experimental/investigational/unproven: Intrathecal baclofen; Experimental/investigational/unproven: Intrathecal clonidine; Experimental/investigational/unproven: Intrathecal corticosteroid; Experimental/investigational/unproven: Intravenous immunoglobulin; Experimental/investigational/unproven: Intravenous magnesium; Experimental/investigational/unproven: Intravenous propofol infusion; Experimental/investigational/unproven: Ketamine metabolite (2R,6R)-hydroxynorketamine; Experimental/investigational/unproven: Low-dose naltrexone; Experimental/investigational/unproven: Metformin; Experimental/investigational/unproven: Movement representation techniques (action observation, mirror therapy, motor imagery); Experimental/investigational/unproven: Multi-site continuous peripheral nerve catheters; Experimental/investigational/unproven: Mycophenolate; Experimental/investigational/unproven: Neuroplasty; Experimental/investigational/unproven: Occlusal splint; Experimental/investigational/unproven: Oral memantine; Experimental/investigational/unproven: Percutaneous peripheral nerve stimulation (with/without ultrasound); Experimental/investigational/unproven: Prism adaptation treatment; Experimental/investigational/unproven: Pulsed light therapy; Experimental/investigational/unproven: Pulsed radiofrequency; Experimental/investigational/unproven: Radiofrequency sympathetic neurotomy; Experimental/investigational/unproven: Sanexas (electroanalgesia); Experimental/investigational/unproven: Sensory retraining; Experimental/investigational/unproven: Tadalafil; Experimental/investigational/unproven: Thalidomide; Experimental/investigational/unproven: Topical dimethyl sulfoxide; Experimental/investigational/unproven: Topical ketamine; Experimental/investigational/unproven: Transcranial direct current stimulation; Experimental/investigational/unproven: Transcranial magnetic stimulation; Experimental/investigational/unproven: Tumor necrosis factor-alpha antagonists (adalimumab, certolizumab, etanercept, golimumab, infliximab); Experimental/investigational/unproven: Virtual body swapping. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for CRPS/RSD Treatments?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Note: For clinical diagnostic criteria for complex regional pain syndrome, see Appendix for the Budapest Criteria.
What does Aetna exclude for CRPS/RSD Treatments?
Policy exclusions and limitations: Continuous epidural analgesia is experimental, investigational, or unproven for the treatment of CRPS when the medically-necessary criteria are NOT met; Additional sympathetic block injections beyond 3 are NOT medically necessary if the member experiences no pain relief after the first 3 injections; It is NOT medically necessary to repeat sympathetic blocks more frequently than once every 7 days; Experimental/investigational/unproven: Intravenous administration of guanethidine, ketamine (including 'ketamine coma') for CRPS; Experimental/investigational/unproven: Intravenous administration of lidocaine or midazolam for CRPS; Experimental/investigational/unproven: Intrapleural analgesia for CRPS with thoracic dermatomes involvement; Experimental/investigational/unproven: Neurolysis of the spinal accessory nerve; Experimental/investigational/unproven: Amputation; Experimental/investigational/unproven: Bier block; Experimental/investigational/unproven: Bio-Electro-Magnetic-Energy-Regulation (BEMER) magneto-therapy; Experimental/investigational/unproven: Bisphosphonates; Experimental/investigational/unproven: Botulinum toxin; Experimental/investigational/unproven: Bupivacaine brachial plexus block; Experimental/investigational/unproven: Combined dorsal root ganglion and dorsal column spinal cord stimulation; Experimental/investigational/unproven: Combined transcranial direct current stimulation and TENS; Experimental/investigational/unproven: Compression sleeve; Experimental/investigational/unproven: Electroconvulsive therapy; Experimental/investigational/unproven: Exergame therapy; Experimental/investigational/unproven: Free-flap surgery and vein wrapping; Experimental/investigational/unproven: Hypnosis; Experimental/investigational/unproven: Interleukin-1 receptor antagonist (anakinra, canakinumab, rilonacept, sarilumab, tocilizumab); Experimental/investigational/unproven: Intrathecal adenosine; Experimental/investigational/unproven: Intrathecal baclofen; Experimental/investigational/unproven: Intrathecal clonidine; Experimental/investigational/unproven: Intrathecal corticosteroid; Experimental/investigational/unproven: Intravenous immunoglobulin; Experimental/investigational/unproven: Intravenous magnesium; Experimental/investigational/unproven: Intravenous propofol infusion; Experimental/investigational/unproven: Ketamine metabolite (2R,6R)-hydroxynorketamine; Experimental/investigational/unproven: Low-dose naltrexone; Experimental/investigational/unproven: Metformin; Experimental/investigational/unproven: Movement representation techniques (action observation, mirror therapy, motor imagery); Experimental/investigational/unproven: Multi-site continuous peripheral nerve catheters; Experimental/investigational/unproven: Mycophenolate; Experimental/investigational/unproven: Neuroplasty; Experimental/investigational/unproven: Occlusal splint; Experimental/investigational/unproven: Oral memantine; Experimental/investigational/unproven: Percutaneous peripheral nerve stimulation (with/without ultrasound); Experimental/investigational/unproven: Prism adaptation treatment; Experimental/investigational/unproven: Pulsed light therapy; Experimental/investigational/unproven: Pulsed radiofrequency; Experimental/investigational/unproven: Radiofrequency sympathetic neurotomy; Experimental/investigational/unproven: Sanexas (electroanalgesia); Experimental/investigational/unproven: Sensory retraining; Experimental/investigational/unproven: Tadalafil; Experimental/investigational/unproven: Thalidomide; Experimental/investigational/unproven: Topical dimethyl sulfoxide; Experimental/investigational/unproven: Topical ketamine; Experimental/investigational/unproven: Transcranial direct current stimulation; Experimental/investigational/unproven: Transcranial magnetic stimulation; Experimental/investigational/unproven: Tumor necrosis factor-alpha antagonists (adalimumab, certolizumab, etanercept, golimumab, infliximab); Experimental/investigational/unproven: Virtual body swapping. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0447 — CRPS/RSD Treatments

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0447 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.