Local Coverage Determination (LCD)

Peripheral Nerve Blocks

L36850

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L36850
Original ICD-9 LCD ID
Not Applicable
LCD Title
Peripheral Nerve Blocks
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL36850
Original Effective Date
For services performed on or after 05/01/2017
Revision Effective Date
For services performed on or after 11/21/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
03/16/2017
Notice Period End Date
04/30/2017
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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
Section 50 Payment for Anesthesiology Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Peripheral nerves can be the cause of pain in a variety of conditions. Sometimes the nerves are the source of the pain and sometimes the nerves merely are carrying impulses from painful tissues. 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 not be effective at providing long term relief.

Indications:

Peripheral nerve blocks will be considered medically reasonable and necessary for normally temporary 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 but this is only for diagnostic purposes and not long term treatment.

  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 but this is only for diagnostic purposes and not long term treatment.

  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 localized head trauma 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, or 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

 A. 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.

 B. 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.

Additional 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.

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. However, its billing must conform to National Correct Coding Initiative edit policy. (NCCI Policy Manual for Medicare Services Chapter II Anesthesia Services)

Limitations:

The signs and symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. They cannot be for clinical situations as mentioned below where nerve blocks are not medically necessary as per this LCD. 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. 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.

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.

There is insufficient evidence to support the use of peripheral nerve blocks in the treatment of diabetic peripheral neuropathy, peripheral neuropathies caused by other underlying systemic diseases or peripheral neuropathies causes such as degenerative or idiopathic reasons. Medical management using systemic medications is clinically indicated for the treatment of these conditions.

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.

The use of ultrasound guidance in conjunction with these non-covered injections is also considered not medically necessary and will result in denial.

Note: the term "Morton's neuroma" is used in this document generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton's neuroma (lesion within the third intermetatarsal space), Heuter's neuroma (first intermetatarsal space), Hauser's neuroma (second intermetatarsal space) and Iselin's neuroma (fourth intermetatarsal space). This LCD applies to each such condition.

Injection into neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local anesthetics and/or steroids should be short- term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause.

Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable and not supported by peer literature that is indexed in PubMed of the US National Library of Medicine of the National Institutes of Health (NIH).

"Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths and their origins/insertions, or any tissue are non-covered procedures.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

Other Contractor LCD (First Coast Service Options, Inc.) (LCD ID L33933) which includes the following sources:

Capdevila X, Pirat P, Bringuier S, et. al. 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.. 2005;103(5)
:921-923.

Cernak C, Marriott E, Martini J, Fleischmann J, Silvani B, McDermott M. Electrical current and local anesthetic combination successfully treats pain associated with diabetic neuropathy. Practical Pain Management. 2012;12(3):23-36.

Cohen NP, Levine WN, Marra G, Polllock RG, Flatow EL, Brown AR. Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: A report of 100 consecutive cases. Journal of Shoulder Elbow Surgery. 2000;9:268-274.

Dworkin RH, O’Connor AB, Kent J, Mackey SC, Raja SN, Stacey BR. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain. 2013. http://dx.doi.org/10.1016/j.pain.2013.06.004

Evans H, Steele S, Neilsen KC, Tucker MS, Klein SM. Peripheral nerve blocks and continuous catheter techniques. Anesthesiology Clinics of North America. 2005;23(1):141-162.

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

Grabinsky A. Mechanisms of Neural Blockade. Pain Physician. 2005;8:411-416.

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

Manchikanti L, Singh V, Kloth D, et. al. Inerventional techniques in the management of chronic pain. Pain Physician. 2001;4(1) 24-98.

Manchikanti L, Staats PS, Singh V, Shultz, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003;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 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.http://www.guideline.gov/content.aspx?id=33038&search=diabetic+neuropathy. Accessed on 06/25/2013.

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

References received during comment period 10/19/2016 through 12/02/2016:

Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia. 2010;105(6):842–852.

Voigt CL, Murphy MO. Occipital nerve blocks in the treatment of headaches: safety and efficacy. Journal of Emergency Medicine. 2015;48(I):115-129.

Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
11/21/2019 R4

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A57452. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
10/01/2018 R3

Due to the annual ICD-10-CM updates, ICD-10 codes C43.11, C43.12, C4A.11, C4A.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, D22.11, D22.12, D23.11, and D23.12 have been deleted from Group 1 and Group 2 and the following ICD-10 codes have been added as replacements; C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1921, C44.1922. C44.1991, C44.1992, D22.111, D22.112, D22.121, D22.122, D23.111, D23.112, D23.121, and D23.122. In addition, ICD-10 codes C44.1321, C44.1322, C44.1391, C44.1392, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, and D04.122 have also been added to Group 1 and Group 2.

DATE (10/01/2018): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R2

Based on a practitioner request, ICD-10-CM codes M54.31, M54.32, M54.41 and M54.42 were added to Group 1 in the “ICD-10-CM Codes that Support Medical Necessity” section for dates of service on or after 10/01/2017.

DATE (04/05/2018): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Request for Coverage by a Practitioner (Part B)
10/01/2017 R1

Due to the annual ICD-10-CM code update, ICD-10-CM code D47.0 was deleted from Groups 1 and 2 the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM codes D47.01, D47.02 and D47.09 were added as the replacement codes.

ICD-10-CM Codes C96.20, C96.21, C96.22 and C96.29 were added to the range of C88.2 - C96.4 in Groups 1 and 2 in the “ICD-10-CM Codes that Support Medical Necessity” section.

Based on two practitioner/provider requests, ICD-10-CM codes G54.8, G56.03, G56.43, G57.13, G57.73 and G57.93 were added to Group 1, ICD-10-CM codes G54.8, G56.03, G57.13 and G57.53 to Group 2 and ICD-10-CM code G57.63 to Group 3 in the “ICD-10-CM Codes that Support Medical Necessity” section for dates of service on or after 05/01/2017.

DATE (10/01/2017): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

 

  • Request for Coverage by a Practitioner (Part B)
  • Revisions Due To ICD-10-CM Code Changes
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Updated On Effective Dates Status
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