Local Coverage Determination (LCD)

Continuous Peripheral Nerve Blocks (CPNB)

L37641

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Contractor Information

LCD Information

Document Information

LCD ID
L37641
LCD Title
Continuous Peripheral Nerve Blocks (CPNB)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 01/29/2018
Revision Effective Date
For services performed on or after 06/23/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/14/2017
Notice Period End Date
01/28/2018
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861(s)(2)(A) and (s)(2)(B) describe coverage benefits for services and supplies ‘incident to’ professional services of the physician.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

CMS Internet-Only Manual, Pub.100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.3 Acupuncture, §30.3.1 Acupuncture for Fibromyalgia, and §30.3.2 Acupuncture for Osteoarthritis.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This Local Coverage Determination (LCD) specifically addresses continuous paravertebral, interscalene, supraclavicular, infraclavicular, interscalene brachial plexus, axillary, femoral, lumbar plexus, sciatic, and popliteal (sciatic) nerve blocks.

Background

Out of necessity, multiple continuous peripheral nerve blocks (CPNB) were administered in Operation Iraqi Freedom in 2003. Real-time imaging (portable ultrasound) and peripheral nerve stimulation (PNS) have revolutionized the practice of CPNB anesthesia by providing objective evidence of needle proximity to targeted nerves. In the majority of peripheral nerve blocks (PNB), stimulation of nerves at a current of 0.5 mA or less suggests accurate needle placement for injection of local anesthetic. Differential blockade to achieve pain and temperature block while minimizing motor block can be achieved by using levorotatory enantiomers of local anesthetics and delivering specific concentrations to the nerve. A variety of anesthesia textbooks publish maximum recommended dosages for local anesthetics in an attempt to prevent high dose injections leading to toxicity. Because local anesthetic toxicity is related more to intravascular injection than to total dose, some physicians have suggested maximum dose recommendations are irrelevant. It is reasonable to assume that intravascular injections will occur, and practitioners of regional anesthesia should select techniques designed to minimize their occurrence.

This LCD addresses the use of these blocks in the definition and treatment of pain and conditions primarily treated with nerve blockade, such as complex regional pain syndrome (CRPS) and certain hyperhidroses. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for 3 months or more. CPNB involves the percutaneous insertion of a catheter directly adjacent to a peripheral nerve. The catheter is then infused with local anesthetic resulting in potent, site-specific analgesia that lasts well beyond the normal duration of a single injection nerve block. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency.

Prior to blockade, all patients with pain complaints require an evaluation that includes an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary comprehensive evaluation.

Indications

CPNB may be performed for several reasons and may be covered for the following purposes:

  1. Therapeutic - to treat painful conditions or hyperhidroses that respond to nerve blocks

  2. Prognostic - to predict the outcome of long-lasting interventions (e.g., neurolysis, rhizotomy)

 Limitations

  1. CPNB is a physician (or other qualified practitioner) service.

  2. There is no coverage of CPNB services and supplies ‘incident to’ the professional services of a physician (or other qualified practitioner) in private practice.

  3. CPNB should be performed with real-time ultrasound imaging and/or PNS to help prevent undesirable side effects such as muscle weakness.

  4. In general, different types of nerve blocks should not be performed at the same setting as other blocks in the same body region.

  5. When not used as the primary mode of anesthesia, the medically reasonable and necessary placement of CPNB may be reimbursable. Examples:

    1. A continuous femoral nerve block placed to provide postoperative analgesia for an anterior cruciate ligament repair or a total knee replacement could be reported separately from the surgical anesthesia.

    2. For shoulder surgery performed under continuous interscalene brachial plexus block along with a general anesthetic as the primary anesthesia, the block would be separately reportable as long as it will be used for postoperative pain control.

    3. A continuous brachial plexus block might also provide both the anesthesia and the postoperative pain control for an open reduction of a wrist fracture. Only the anesthesia code would be reported.
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

Documentation of the need for CPNB status should be included in the progress notes of each visit/session.

Medical record documentation must support:

  • The service was performed by a physician,
  • Catheter placement was enhanced with use of imaging and/or nerve stimulation, and
  • The medical necessity of CPNB versus other modalities (single injection).

All indications must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

Sources of Information
N/A
Bibliography
  1. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg. 2003;96:247-252.
  2. Buckenmaier CC, Shields CH, Auton AA, et al. Continuous peripheral nerve block in combat casualties receiving low-molecular weight heparin. British Journal of Anaesthesia. 2006;97:874-877.
  3. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009;110(1):182-188.
  4. Casati A, Fanelli G, Koscielniak-Nielsen Z, et al. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters. Anesth Analg. 2005;101:1192-1197.
  5. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: Bacterial colonization, infectious rate and adverse effects. Anesth Analg. 2001;93:1045-1049.
  6. Di Benedetto P, Casati A, Bertini L, Fanelli G, Chelly JE. Postoperative analgesia with continuous sciatic nerve block after foot surgery: A prospective, randomized comparison between the popliteal and subgluteal approaches. Anesth Analg. 2002;94:996-1000.
  7. Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: A systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. 2008;100(2):154-164.
  8. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology. 2008;108(4):703-713.
  9. Ilfeld BM, Vandenborne K, Duncan PW, et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006;105(5):999-1007.
  10. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesthesiology. 2002;96(6);1297-1304.
  11. Ilfeld BM, Le LT, Ramjohn J, et al. The effects of local anesthetic concentration and dose on continuous infraclavicular nerve blocks: A multicenter, randomized, observer-masked, controlled study. Anesth Analg. 2009;108(1):345-350.
  12. Plunkett AR, Brown DS, Rogers JM, Buckenmaier CC. Supraclavicular continuous peripheral nerve block in a wounded soldier: When ultrasound is the only option. British Journal of Anaesthesia. 2006;97(5):715-717.
  13. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opiods? A meta-analysis. Anesth Analg. 2006;102:248-257.
  14. Swenson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: An experience in 620 patients. Anesth Analg. 2006;103(6):1436-1443.
  15. Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg. 2007;104(6):1578-1582.
  16. Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B. A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg. 2006;102:1240-1246.
  17. Zink W, Bohl JRE, Hacke N, Sinner B, Martin E, Graf BM. The long term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks. Anesth Analg. 2005;101:548-554.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
06/23/2022 R6

Under CMS National Coverage Policy updated section headings for regulations. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/10/2019 R5

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB) A56607 article.

 At this time 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.

  • Provider Education/Guidance
06/06/2019 R4

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB) A56607 article.

At this time 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.

  • Provider Education/Guidance
03/14/2019 R3

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were defined and inserted where appropriate throughout the LCD. 

At this time 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.

  • Provider Education/Guidance
  • Typographical Error
02/26/2018 R2 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R1

The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.

  • Other

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
06/16/2022 06/23/2022 - N/A Currently in Effect You are here
10/04/2019 10/10/2019 - 06/22/2022 Superseded View
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