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MP 2.01.85

Neural Therapy


Medical Policy     
Section
Medicine 
Original Policy Date
12/18/2011
Last Review Status/Date
Reviewed with literature search/12:2014
Issue
12:2014
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

 

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 is believed to reestablish the normal resting potential of nerves and flow of energy. Alternative theories include fascial continuity, the ground (matrix) system, and the lymphatic system. (1)

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, 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.


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 one session to a series of sessions over a period of weeks or months.

There are no specific HCPCS codes for these local anesthetics when injected in this fashion (there is a code for IV lidocaine). The procedure would be reported using CPT codes for therapeutic injection such as:

20550: Injection(s); single tendon sheath, or ligament, aponeurosis

20551: Injection(s); single tendon origin/insertion

20552- 20553: Code range for injection(s); single or multiple trigger point(s)

64400-64450: Code range for injection, anesthetic agent into nerves

64479-64484: Code range for injection, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance by spinal region

64505-64530: Code range for injection, anesthetic agent into autonomic nerves/ganglia

96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular


Benefit Application
BlueCard/National Account Issues

 

No applicable information.


Rationale

 

This policy was created in 2011 and updated periodically using the MEDLINE database. The most recent literature update was performed through November 24, 2014.

Neural therapy is an alternative medicine modality that was developed in Germany and is most commonly reported in Europe. Most of the literature on neural therapy consists of non-English-language publications.

In 2012, Hui et al reported a nonblinded randomized controlled trial of complementary and alternative medicine (CAM) for chronic herpes zoster-related pain.(2) The 59 patients included in the trial had a confirmed diagnosis of herpes zoster of at least 30 days in duration (median, 4.8 months; range, 1 month to 15 years) and with at least moderate postherpetic neuralgia pain (≥4 on a 10-point Likert scale). The therapy included 3 weeks of neural therapy (injection of 1% procaine at up to 6 points along the affected dermatome) along with other therapies from traditional Chinese medicine (ie, acupuncture, cupping and bleeding, Chinese herbs) and meditation. A wait-list control group received the same treatment beginning 3 weeks after randomization. Intention-to-treat analysis of pain scores at 3 weeks showed significant
improvement in the CAM group (baseline, 7.5; posttreatment, 2.3), with little change in the wait-list control group (baseline, 7.8; 3 weeks, 7.2). A reduction in pain of at least 50% was observed in 66.7% of patients in the treatment group compared with 8.7% in the control group. In the 56% of patients who responded to a questionnaire after 1 to 2 years, 78.8% reported continued relief of pain. Interpretation of the  results is limited by the multiple interventions provided and the possibility of a placebo effect in this nonblinded study.

One English-language report from 1999 describes a small double-blind, randomized, placebo-controlled crossover trial in 21 patients with multiple sclerosis.(3) Anesthetic or saline was injected at acupuncture points in the ankle and at 14 or 15 points around the circumference of the head. Patients received 2 injections of anesthetic or saline in the first week; in the second week all patients received anesthetic injections. At the end of the first week, 8 of 11 patients in the active treatment group and 1 of 10 in the placebo group had improved in 1 or more functions on the Kurtzke scale. Therapy was continued as needed for up to 3.5 years, with long-term improvements being reported in over 50% of patients. At the time of publication, the authors reported having treated more than 300 patients with multiple sclerosis with this approach.

A 2013 nonrandomized comparative study from Turkey compared neural therapy (n=33) with physical therapy (PT; n=27) for the treatment of chronic low back pain.(4) The average duration of symptoms before treatment was 13.78 months. Patients who had not previously been treated with PT were assigned to the PT group, and patients who had previously failed PT were assigned to the neural therapy group. PT consisted of exercises, hot pack, ultrasound, and transcutaneous electrical nerve stimulation (TENS) over 15 sessions. Neural therapy consisted of anesthetic injection into scars, trigger points, and acupuncture points over 5 sessions. Outcome measurements included the visual analog score for pain, the Roland-Morris Disability Questionnaire for disability, the Nottingham Health Profile for quality of life, and the
Hospital Anxiety Depression Scale for depression, anxiety, and quality of life. The neural therapy group exhibited greater disability and worse quality of life at baseline. Both groups improved over time, and there was greater improvement in the neural therapy group on some of the outcome measures. Interpretation of this study is limited due to the nonrandomized treatment assignment, lack of comparability between groups at baseline, and lack of a placebo control.

In a case series from 1990, Arnér et al reported prolonged relief of neuralgia after regional anesthetic blocks in 25 of 38 patients.(5) All patients had neuralgia due to nerve injury (endogenous entrapment or surgical or accidental trauma) with a mean pain duration of 3.8 years (range, 6 months to 12 years). All patients had a demonstrable sensory deficit or sensory hyperfunction within the cutaneous territory supplied by the injured nerve as measured by quantitative sensory testing. None of the patients had the classical type of complex regional pain syndrome (previously called reflex sympathetic dystrophy). Each patient received a series of 2 to 23 blocks (median, 5.2 blocks) of bupivacaine. Sixteen patients experienced subjective improvement for weeks to months after the series of blocks, but a second series of blocks was effective in only 7 of these patients. Four of the 7 reported sustained improvement after 1 to 4 years. Thirty of the 38 patients did not experience long-lasting pain relief and were subsequently treated with TENS. The report concluded that nerve blocks with local anesthetics rarely provide long-term, complete relief of neuralgia.

In 2011, Schmittinger et al reported a case of brainstem hemorrhage following neural therapy for decreased libido.(6)

Summary of Evidence

Neural therapy is an alternative medicine modality that involves the injection of a local anesthetic into various tissues to treat chronic pain and illness. There are few English-language reports, and the available studies have methodologic limitations that preclude conclusions on efficacy. Therefore, the evidence is insufficient to permit conclusions concerning the health benefit of this procedure, and neural therapy is considered investigational.

Practice Guidelines and Position Statements

The American Association of Orthopaedic Medicine, which provides information and educational programs on the nonsurgical treatment of musculoskeletal problems, describes neural therapy on its website and provides a link for instructional courses on the procedure.(7)

U.S. Preventive Services Task Force Recommendations
Not applicable.

Medicare National Coverage
There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.

 References: 

  1. Frank BL. Neural therapy. Phys Med Rehabil Clin N Am. Aug 1999;10(3):573-582, viii. PMID 10516978
  2. Hui F, Boyle E, Vayda E, et al. A randomized controlled trial of a multifaceted integrated complementaryalternative therapy for chronic herpes zoster-related pain. Altern Med Rev. Mar 2012;17(1):57-68. PMID 22502623
  3. Gibson RG, Gibson SL. Neural therapy in the treatment of multiple sclerosis. J Altern Complement Med. Dec 1999;5(6):543-552. PMID 10630348
  4. 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. PMID 24146471
  5. Arnér S, Lindblom U, Meyerson BA, et al. Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies. Pain. Dec 1990;43(3):287-297. PMID 1705693
  6. Schmittinger CA, Schar R, Fung C, et al. Brainstem hemorrhage after neural therapy for decreased libido in a 31-year-old woman. J Neurol. Jul 2011;258(7):1354-1355. PMID 21286741
  7. American Association of Orthopaedic Medicine. Neural Therapy. 2013; http://www.aaomed.org/Neural-therapy. Accessed November 24, 2014.

     

Codes

Number

Description

CPT

 

No specific codes, see Policy Guidelines

ICD-9 Diagnosis

 

Investigational for all diagnoses

ICD-10-CM (effective 10/1/15)  

Investigational for all diagnoses

ICD-10-PCS (effective 10/1/15)    ICD-10-PCS codes are only used for inpatient services. There are no ICD-10-PCS codes for this procedure.

 


Index
Anesthetic, peripheral
Neural acupuncture
Neural therapy


Policy History

Date Action Reason
12/08/11 New policy; add to Medicine section Policy created with literature search through October 2011; considered investigational for all indications
12/13/12 Replace Policy Policy updated with literature search through September 2012; reference 3 added; policy statement unchanged.
12/11/14 Replace policy Policy updated with literature review through November 24, 2014; reference 7 added; policy statement unchanged