BlueCross BlueShield of Tennessee Medical Policy Manual

Ablation Procedure for Peripheral Neuromas

DESCRIPTION

A neuroma is pathology of peripheral nerve that develops as part of a normal reparative process after injury or as a result of chronic irritation. Morton intermetatarsal neuroma is a common and painful compression neuropathy of the common digital nerve of the foot that may also be referred to as interdigital neuroma, interdigital neuritis, and interdigital or Morton metatarsalgia. Morton neuroma is usually associated with a throbbing, burning, or shooting pain localized to the plantar aspect of the foot. It is typically located between the third and fourth metatarsal heads, although it may appear in other proximal locations. It is histologically characterized by perineural fibrosis, endoneurial edema, axonal degeneration and local vascular proliferation.

Management of individuals diagnosed with Morton neuroma typically begins with conservative approaches, such as the use of metatarsal pads in shoes and orthotic devices that alter supination and pronation of the affected foot. These approaches try to reduce pressure and irritation of the affected nerve. They may provide relief but they do not alter the underlying pathology. Surgical intervention is considered the definitive therapy.

Alternative approaches under investigation to treat refractory Morton neuroma include minimally invasive procedures aimed at in situ destruction of the pathology.  These include radiofrequency ablation (RFA), cryoablation (also known as cryoneurolysis, cryolysis, cryoanalgesia), and chemical neurolysis of the nerve with alcohol injections.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

No controlled studies were found in the published literature that validate the application of ablation procedures for peripheral neuromas or provide comparisons to other forms of treatment.

SOURCES

American College of Foot and Ankle Surgeons. (2009). Diagnosis and treatment of forefoot disorders: Section 3. Morton’s intermetatarsal neuroma. Retrieved July 5, 2017 from http://www.jfas.org/article/S1067-2516(08)00496-1/pdf.

Association of Extremity Nerve Surgeons. (2014). Clinical practice guidelines. Retrieved July 5, 2017 from http://www.aens.us/images/aens/AENSGuidelinesFinal-12082014.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2017). Ablation procedures for peripheral neuromas. (7.01.147). Retrieved July 3, 2017 from BlueWeb. (37 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2017). Alcohol injections for treatment of peripheral neuromas. (2.01.97). Retrieved July 3, 2017 from BlueWeb. (19 articles and/or guidelines reviewed)

Brooks, D., Parr, A., & Bryceson, W. (2017). Three cycles of radiofrequency ablation are more efficacious than two in the management of Morton’s neuroma. Foot & Ankle Specialist, 2017 May 1:1938640017709905. Doi:10.1177/1938640017709905. [Epub ahead of print]. Abstract retrieved July 5, 2017 from PubMed database.

Cazzato, R., garnon, J., Ramamurthy, N., Tsoumakidou, G., Caudrelier, J., Thenint, M., et al. (2016). Percutaneous MR-guided cryoablation of Morton’s neuroma: rationale and technical details after the first 20 patients.

Chuter, G., Chua, Y., Connell, D., & Blackney, M. (2013). Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton’s) neuroma. Skeletal Radiology, 42 (1), 107-111. Abstract retrieved March 16, 2015 from PubMed database. Cardiovascular and Interventional Radiology, 39 (10), 1491-1498. Abstract retrieved July 5, 2017 from PubMed database.

National Institute for Health and Care Excellence. (2015, December). Radiofrequency ablation for symptomatic interdigital (Morton’s) neuroma. Retrieved May 3, 2016 from nice.org.uk/guidance/ipg539.

Pasquali, C., Vulcano, E., Novario, R., Varotto, D., Montoli, C., & Volpe, A. (2015). Ultrasound-guided alcohol injection for Morton’s neuroma. Foot & Ankle Specialist, 36 (1), 55-59. Abstract retrieved July 5, 2017 from PubMed database.

Winifred S. Hayes, Inc., Search & Summary. (2017, April). Peripheral nerve ablation for treatment of Morton’s neuroma. Retrieved July 5, 2017 from www.Hayesinc.com/subscribers. (4 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  8/8/2015

MOST RECENT REVIEW DATE:  11/1/2017

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.