Peripheral Nerve Blocks

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Peripheral Nerve Blocks. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Peripheral Nerve Blocks and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site. 

Internet Only Manual (IOM) Citations: 

• CMS IOM Publication 100-04, Medicare Claims Processing Manual,
• Chapter 12, Section 50 Payment for Anesthesia Services
• Chapter 23, Section 20.9 National Correct Coding Initiative (CCI)
• CMS IOM Publication 100-08, Medicare Program Integrity Manual,
• Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD 

Social Security Act (Title XVIII) Standard References:  

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. 
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

History/Background and/or General Information

Peripheral nerves can be the cause of pain in a variety of conditions. Examples may include: post-herniorrhaphy pain (ilioinguinal/iliohypogastric/genitofemoral), iliac crest harvest syndromes (cluneal nerve, lateral femoral cutaneous nerve), carpal tunnel syndrome (median nerve), Morton’s neuroma, facial pain and headaches (trigeminal and occipital nerve).

Peripheral nerve blocks may be used for both diagnostic and therapeutic purposes. Diagnostically, a peripheral nerve block allows the clinician to isolate the specific cause of pain in an individual patient. The injection of local anesthetic, with or without steroid may also provide an extended therapeutic benefit. If the patient does not achieve sustained relief a denervation procedure via chemical, cryoneurolysis or radiofrequency may be effective at providing long term relief.

Covered Indications

Peripheral nerve blocks will be considered medically reasonable and necessary for conditions such as the following diagnostic and therapeutic purposes:

1. When the patient’s pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation. 
2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome. 
3. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear. 
4. When an occipital nerve block is used to confirm the clinical impression of the presence of occipital neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as the result of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or bilateral, constant or intermittent. Nerve injury secondary to a blow to the back of the head or trauma to the nerve from a scalp laceration can also cause this condition. Most commonly it is caused by an entrapment of the occipital nerve in its course from its origin from the C2 nerve root to its entrance into the scalp through the mid portion of the superior nuchal line. Blockage of the occipital nerve can confirm the clinical impression of occipital neuralgia particularly if the clinical picture is not entirely typical. If only temporary relief of symptoms is obtained, neurolysis of the greater occipital nerve may be considered via multiple techniques including radiofrequency and cryoanalgesia. In addition, the lesser and third occipital nerves can be involved in the pathology of headaches, and can be treated in a similar manner.
5. When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve. Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a syndrome of pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When the history and examination point to the diagnosis, a suprascapular nerve block leading to relief of pain can confirm it. This may be followed by injection of depository steroids that sometime provide lasting relief.
6. When the trigeminal nerve is blocked centrally at the trigeminal ganglion, along one of the three divisions or at one of the many peripheral terminal branches (i.e., supraorbital nerve).
7. Nerve blocks as preemptive analgesia
1.  When a single injection peripheral nerve block provides post-surgical pain control
   1. during the transition to oral analgesics
   2. in those procedures which cause severe pain normally uncontrolled by oral analgesics
   3. in cases otherwise requiring control with intravenous or parenteral narcotics.
   4. in cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects, etc. 
2. When a continuous peripheral nerve block provides the same as above, and furthermore may provide extended (i.e., one to five or more days) relief as a result of chronic administration of anesthetic.

Preemptive analgesia starts before surgery, and a presumption of medical necessity is being made before the fact. Therefore, based on generally accepted clinical standards and evidence in peer reviewed medical literature the surgical procedure must be of such nature that the patient would benefit from the preemptive analgesia.

Medical management using medications, behavioral therapy, and physical therapy should be used (when appropriate) in conjunction with peripheral nerve block.

Injection of depository steroids, may offer only temporary relief. In some cases, neurolysis may be appropriate to provide lasting relief.

Limitations

1. The signs and symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. More than three injections per anatomic site (e.g., specific nerve, plexus or branch as defined by the CPT code description) in a six month period will be denied.
2. 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. If the patient does not achieve progressively sustained relief after receiving two to three repeat peripheral nerve block injections on the same anatomical site, then alternative therapeutic options should be explored.
3. There is insufficient evidence to support the use of peripheral nerve blocks in the treatment of diabetic peripheral neuropathy.
4. The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary. Medical management using systemic medications is clinically indicated for the treatment of these conditions.
5. At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases.
6. More than three injections per anatomic site (specific nerve, plexus or branch as defined by the CPT code description) in a six month period will be denied.
7. More than two anatomic sites (specific nerve, plexus or branch as defined by the CPT code description) injected at any one session will be denied.

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

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Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Peripheral Nerve Blocks (A57788) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Peripheral Nerve Blocks (A57788) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

First Coast Service Options, Inc. reference LCD number – L29466

Capdevila, X., Pirat, P., Bringuier, S., Gaertner, E., Singelyn, F., Bernard, N., Choquet, O., Bouazia, H., & Bonnet, F. (2005). Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: A Multicenter prospective analysis of the quality of postoperative analgesia and complications in 1, 416 patients. Anesthesiology.103: 5: 921-3.

Cernak, C., Marriott, E., Martini, J., Fleischmann, J., Silvani, B., McDermott, M., (2012). Electrical current and local anesthetic combination successfully treats pain associated with diabetic neuropathy. Practical Pain Management, 12, (3). 23.36

Cohen, N.P., Levine, W.N., Marra, G., Polllock, R.G., Flatow, E.L., Brown, A.R. (2000).Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: A report of 100 consecutive cases. Journal of Shoulder Elbow Surgery. 9: 268-74.

Dworkin, R.H., O’Connor, A.B., Kent, J., Mackey, S. C., Raja, S.N., Stacey, B.R., et al. (2013). Interventional management of neuropathic pain: NeuPSIG recommendations. Pain.

Evans, H., Steele, S., Neilsen, K.C., Tucker, M.S., Klein, S.M. (2005). Peripheral nerve blocks and continuous catheter techniques. Anesthesiology Clinics of North America. 23 (1): 141-62.

Gottschalk, A. Ochroch, E.E. (2003). Preemptive analgesia. What do we do now? Anesthesiology. 98(1): 280-281.

Grabinsky, A. (2005). Mechanisms of Neural Blockade. Pain Physician. 8:411-416.

Kissin, I. (2000). Preemptive analgesia. Anesthesiology. 93(4): 1138-1143.

Manchikanti, L., Singh, V., Kloth, D., Slipman, C.W., Jasper, J., Trescot, A.M., Varley, K.G., Alturi, S.L., Giron, C., Curran, M.J., Rivera, J., Baha, A.G., Bakhit, C.E., and Reuter, M.W. (2001). Inerventional techniques in the management of chronic pain. Pain Physician 4(1) 24-98.

Manchikanti, L., Staats, P.S., Singh, V., Shultz, D.M., Vilims, B.D., Jasper, J.F., Kloth, D.S., Trescot, A.M., Hansen, H.C., Falasca, T.D., Raczz, G.B., Deer, T.R., et al. (2003). Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 6: 3-81.

Miller, R.D. (2000). Miller: Anesthesia, 5th ed. Philadelphia: Churchill Livingstone.

National Correct Coding Initiative Policy Manual for Medicare Services, (2013) Chapter 11

National Correct Coding Initiative Policy Manual for Medicare Services, (2017), Effective January 1, 2018, Chapter 11

National Guideline Clearinghouse. (2011). Evidence-based guideline: treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation.

Odell, R., Sorgnard, R., (2011). New techniques combines electrical currents and local anesthetic for pain management. Practical Pain Management, 11(5), 52-68.

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