Nerve Grafting and Reconstruction: Selected Indications (CPB 0416, reviewed 2025-06-09)
Summary
Aetna's Clinical Policy Bulletin 0416 sets the medical necessity rules for nerve grafting and nerve reconstruction. Nerve allograft (Avance) is medically necessary for repair of short-to-medium sensory nerve gaps of 30 mm or less in the upper extremity, while nerve allograft for motor nerve repair, long gaps over 30 mm, large-diameter nerves, lower extremity reconstruction and all other indications not listed as medically necessary is experimental, investigational or unproven. Collagen conduits and synthetic or xenograft nerve grafts, including the AxoGen, Integra, NeuraGen, NeuraWrap, Neuromatrix and NeuroMend products, are experimental, investigational or unproven for all indications, and so are sural, cavernous and genitofemoral nerve grafts during radical retropubic prostatectomy, nerve wrapping for compression neuropathy, cross-palm nerve grafting for ulnar neuropathy, vascularized nerve grafts, intra-operative electrical stimulation of peripheral nerves in the upper extremity, and phrenic nerve reconstruction for diaphragmatic paralysis (this does not apply to prompt repair of acute phrenic nerve transection due to trauma or surgery).
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