Latest Review Date: November 2024

Category: Surgery                                                                  

POLICY:

Neural therapy is considered investigational for all indications.

POLICY GUIDELINES:

Neural therapy should be distinguished from the use of peripherally injected anesthetic agents for nerve blocks or local anesthesia. The site of the injection for neural therapy may be located far from the source of the pain or injury. The length of treatment can vary from 1 session to a series of sessions over a period of weeks or months.

DESCRIPTION OF PROCEDURE OR SERVICE:

Neural therapy involves the injection of a local anesthetic such as procaine or lidocaine into various tissues such as scars, trigger points, acupuncture points, tendon and ligament insertions, peripheral nerves, autonomic ganglia, the epidural space, and other tissues to treat chronic pain. Neural therapy has been proposed for other chronic illness syndromes such as allergies, infertility, tinnitus, multiple sclerosis, depression, and chronic bowel problems. When the anesthetic agent is injected into traditional acupuncture points, this treatment may be called neural acupuncture.

The practice of neural therapy is based on the belief that energy flows freely through the body. It is proposed that injury, disease, malnutrition, stress, and scar tissue disrupt this flow, creating disturbances in the electrochemical function of tissues and energy imbalances called “interference fields.” Injection of a local anesthetic at specific sites is believed to re-establish the normal resting potential of nerves and flow of energy. Alternative theories include fascial continuity, the ground (matrix) system, and the lymphatic system.

There is a strong focus on treatment of the autonomic nervous system, and injections may be given at a location other than the source of the pain or location of an injury. Neural therapy is promoted mainly to relieve chronic pain. It has also been proposed to be helpful for allergies, hay fever, headaches, multiple sclerosis, arthritis, asthma, hormone imbalances, libido, infertility, tinnitus, chronic bowel problems, sports or muscle injuries, gallbladder, heart, kidney, or liver disease, dizziness, depression, menstrual cramps, and skin and circulation problems.

KEY POINTS:

This policy has been updated regularly with searches of the PubMed database. The most recent literature update was performed through September 27, 2024.

Summary of Evidence:

For individuals who have chronic pain or illness (e.g., pain, allergies, hay fever, headaches, arthritis, asthma, hormone imbalances, libido, infertility, tinnitus, multiple sclerosis, chronic bowel problems, sports or muscle injuries, gallbladder, heart, kidney, or liver disease, dizziness, depression, menstrual cramps, skin and circulation problems) who receive neural therapy, the evidence includes randomized and nonrandomized trials. Relevant outcomes are symptoms, functional outcomes, quality of life, medication use, and treatment-related morbidity. There are few English-language reports assessing the use of neural therapy for pain, and the available studies have methodologic limitations that preclude conclusions on efficacy. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements

American Academy of Neurology

In 2014, the American Academy of Neurology guideline on complementary and alternative therapies for multiple sclerosis stated that there is insufficient evidence to support or refute the efficacy of neural therapy. Due to inadequate data, the guideline classifies neural therapy treatment as ‘unproven’ for this indication. The evidence reviewed was limited to a single Class III study (controlled study with independent outcome assessment) that evaluated the effect of neural therapy on disability in individuals with all forms of multiple sclerosis.  Among 61 individuals with various forms of multiple sclerosis, 69% had improved Expanded Disability Status Scores which were sustained in 29% of individuals during long-term follow-up (2 to 3.5 years). The 2014 guideline was reaffirmed in February 2023.

American College of Obstetricians and Gynecologists

In 2020, the American College of Obstetricians and Gynecologists practice bulletin on chronic pelvic pain recommends trigger point injections (alone or in combination with other treatments) for improving pain and function in individuals with myofascial chronic pelvic pain (Level A recommendation – based on good and consistent scientific evidence). Trigger point injections may be effective for pelvic floor muscle spasm that is refractory to pelvic floor PT and medications. Injection at trigger points in the abdominal wall may be more effective than ischemic compression PT. Examples of medications that can be used for this type of injection include saline, anesthetics, steroids, or opioids; no medication is specifically recommended for or against and the guideline authors speculate that needle injection may itself account for some of the therapeutic effect. Symptom relief may occur rapidly after the first dose, but full benefit may require repeated doses. The 2020 guideline was reaffirmed in 2023.

North American Spine Society

In 2020, the North American Spine Society guideline on the diagnosis and treatment of low back pain states that evidence is insufficient to make a recommendation for or against treatment with trigger point injections (Grade I recommendation – insufficient or conflicting evidence not allowing a recommendation for or against the intervention). Neural therapy and local anesthetic injections are not specifically mentioned, but the guideline reviewed one randomized study (Level II evidence) that compared a single treatment with lidocaine, lidocaine combined with a steroid, a dry needle (acupuncture), and vapocoolant spray plus acupressure. After 2 weeks, pain was improved by 40% to 60% in all groups. Based on this study, the guideline authors concluded that outcomes are similar regardless of the medication used for the trigger point injection.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Neural therapy, neural acupuncture, autonomic response testing (ART), genicular nerve block

APPROVED BY GOVERNING BODIES:

Neural therapy is a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan

CURRENT CODING: 

There are no specific CPT/HCPCS codes for local anesthetics when injected in this fashion.

CPT Codes:

REFERENCES:

1. Altinbilek T, Terzi R, Basaran A, et al. Evaluation of the effects of neural therapy in patients diagnosed with fibromyalgia. Mar 2019; 65(1): 1-8.
2. Atalay NS, Sahin F, Atalay A, et al. Comparison of efficacy of neural therapy and physical therapy in chronic low back pain. Afr J Tradit Complement Altern Med. 2013; 10(3):431-435.
3. Balevi Batur E, Atan T. Neural therapy for fibromyalgia: myth or improving quality of life? Sep 21 2020: e13719.
4. Boluk Senlikci H, Odabasi OS, Ural Nazlikul FG, et al. Effects of local anaesthetics (neural therapy) on pain and hand functions in patients with De Quervain tenosynovitis: A prospective randomised controlled study. Int J Clin Pract. Oct 2021; 75(10): e14581.
5. Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. Mar 2020; 135(3): e98-e109.
6. Egli S, Pfister M, Ludin SM, et al. Long-term results of therapeutic local anesthesia (neural therapy) in 280 referred refractory chronic pain patients. BMC Complement Altern Med. 2015; 15:200.
7. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
8. Learman LA, McHugh KW. Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. Mar 2020; 135(3): e98-e109.
9. Montenegro ML, Braz CA, Rosa-e-Silva JC, et al. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. Dec 01 2015; 15: 175.
10. Nazlikul H, Ural FG, Ozturk GT, et al. Evaluation of neural therapy effect in patients with piriformis syndrome. . 2018; 31(6): 1105-1110.
11. North American Spine Society. Diagnosis and treatment of low back pain. www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf. 2020.
12. Yadav V, Bever C, Bowen J, et al. Summary of evidence-based guideline: complementary and alternative medicine in multiple sclerosis: report of the guideline development subcommittee of the American Academy of Neurology. Neurology. Mar 25 2014; 82(12): 1083-92.

POLICY HISTORY:

Medical Policy Panel, December 2015

Medical Policy Group, January 2016 (2): 2016 New policy created.

Medical Policy Administration Committee, January 2016

Available for comment January 9 through February 22, 2016

Medical Policy Group, May 2017 (7): CPT 96732—corrected to 96372.

Medical Policy Panel, November 2017

Medical Policy Group, November 2017 (7): 2017 Updates to Key Points; no new literature to add. No change in Policy Statement.

Medical Policy Group, December 2018:  2019 Annual Coding Update. Moved CPT code from Current coding section to previous coding. Created previous coding section to include code 64508.

Medical Policy Panel, November 2018

Medical Policy Group, December 2018 (7): Updates to Key Points; no new literature to add. No change in Policy Statement.

Medical Policy Group, June 2019 (3): Removed Combined electrochemical treatment (CET) from Key Words section.

Medical Policy Group, December 2019: 2020 Annual Coding Update.  Added CPT code 64454 to the Current coding section. Moved CPT codes from Current coding section. Updated Previous coding section to include codes 64402, 64410, 64413. Revised CPT codes: 64400, 64405, 64408, 64415-64421, 64425, 64430, 64435, 64445-64450. Revision made for standardization of the code descriptors and clarity.

Medical Policy Panel, November 2019

Medical Policy Group, December 2019 (3): 2019 Updates to Key Points. No changes to policy statement or intent.

Medical Policy Panel, November 2020

Medical Policy Group, December 2020 (3): 2020 Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, November 2021

Medical Policy Group, December 2021 (3): 2021 Updates to Key Points and References. Policy statement updated to remove “not medically necessary.” No other changes to policy statement or intent.

Medical Policy Panel, November 2022

Medical Policy Group, December 2022 (3): 2022 Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Group, January 2023 (3): Removed CPT coding 20550-20551, 64400-64408, 64415-64425, 64430, 64435, 64445-64450, 64454, 64505, 64510, 64517, 64520, 64530, and 96372 for clarification purposes. Removed Previous Coding section.

Medical Policy Panel, November 2023

Medical Policy Group, November 2023 (6) Updates to Key Points, Practice Guidelines, Benefit Application, and References.

Medical Policy Panel, November 2024

Medical Policy Group, November 2024 (9) Updates to Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.