Local Coverage Article Response to Comments

Response to Comments: Peripheral Nerve Blocks


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Article ID
Article Title
Response to Comments: Peripheral Nerve Blocks
Article Type
Response to Comments
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As an important part of Medicare Local Coverage Determination (LCD) development, National Government Services solicits comments from the provider community and from members of the public who may be affected by or interested in our LCDs. The purpose of the advice and comment process is to gain the expertise and experience of those commenting.

We would like to thank those who suggested changes to the LCD for Peripheral Nerve Blocks. The official notice period for the final LCD begins on March 16, 2017 and the final determination will become effective on May 1, 2017.

Response To Comments

1The LCD states: “The signs or symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. Injections beyond three in a six month period will be denied.” Patients that receive peripheral nerve blocks have typically failed many other therapies, and are often using a peripheral nerve block as a last resort. Peripheral nerve blocks are not curative; rather, they can provide ongoing maintenance for a patient suffering from a chronic disease. We believe coverage for peripheral nerve blocks should not be limited to three injections at a specific site, as this type of therapy may be the only form of relief for a patient depending upon their specific situation. With a limitation in the number of peripheral nerve blocks for patients suffering from a chronic disease, we expect patient emergency department visits and hospitalizations to increase due to the lack of this effective treatment. The goal is to provide the least costly and least restrictive care for this patient population. An additional goal of our chronic pain programs is to limit the level of opioid medication as much as possible, due to national concerns about opioid misuse. Peripheral nerve blocks for patients suffering from a chronic disease is an important tool for many to be able to limit or eliminate chronic opioid use. We would encourage National Government Services to reconsider limitations on the number of injections a patient may receive.We will add the following language to the first paragraph in the "Limitations" section to read: These blocks should last at least two months in order to be deemed successful. In rare exceptions with appropriate documentation, there is a limit of three blocks per six month period. We have determined the paragraph cited in the comment was duplicative and will be removed.
2The proposed LCD states, "More than two anatomic sites (e.g., specific nerve, plexus or branch as defined by the CPT code description) injected at any one session will be denied." There are several perioperative situations in which more than two anatomic sites need to be blocked. For example, if a woman is undergoing a mastectomy, bilateral paravertebral blocks need to be performed to provide postoperative analgesia thereby decreasing the dose of postoperative opioids. Given the current opioid epidemic and CDC guidelines for opioids it is imperative that all measures be undertaken to decrease opioid consumptions after surgical procedures. In order to attain adequate post-operative pain relief and spread of the local anesthetic, it may take three levels of injections, which would require billing of 64461 and 64462 twice for the two additional levels. Specifically with paravertebral blocks, the literature indicates that the post-operative pain relief is superior to IV analgesics and it decreases length of stay. In patients who have multiple fractures (e.g. from a motor vehicle accident or trauma) may undergo multiple procedures at once that would necessitate more than two anatomic sites peripheral nerve blocks for post-operative pain relief. Finally with a general medical trend to discharge patients early after surgery more distal peripheral nerve blocks are performed under the guidance of ultrasound to decrease the loss of motor functions and thereby patients to undergo physical therapy and improved outcomes. This is particularly true for patients undergoing orthopedic surgery. Due to the unique situation of perioperative blocks for post-operative pain relief and the need for possible injection of more than two anatomic sites to be blocked, we suggest modification of the language to state "More than two anatomic sites (e.g., specific nerve, plexus or branch as defined by the CPT code description) injected at any one session will be denied except when being used for post-surgical pain control." We will revise the language to read: It is unusual that more than two nerves would need to be blocked at any one session. If more than two nerves are blocked in one session, this may trigger a medical review and the provider must document the medical necessity for more than two blocks in the patient's medical record.
3The second section in the proposed LCD that is of concern is "When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record." In institutions where there are large volumes of peripheral nerve blocks performed in the perioperative setting, there can be a dedicated team to perform the peripheral nerve blocks for post-operative pain relief that is separate of the anesthesia team that provides the anesthesia for the procedure for efficiency purposes. There is no difference in the payment that occurs if a different anesthesiologist performs the peripheral nerve block and it is separately documented. Therefore because it is a separately billable procedure and in light of the common practice of a different anesthesiologist performing the block due to efficiency, we request that you delete this additional documentation requirement. We agree and we will remove the "Documentation Requirement".

Associated Documents

Related Local Coverage Documents
L36850 - Peripheral Nerve Blocks
Related National Coverage Documents
Public Versions
Updated On Effective Dates Status
03/07/2017 05/01/2017 - N/A Currently in Effect You are here