Proposed Local Coverage Determination (LCD)

Nerve Blockade for Treatment of Chronic Pain and Neuropathy


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Proposed LCD
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Contractor Information

Proposed LCD Information

Document Information

Source LCD ID
Proposed LCD ID
Proposed LCD Title
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
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Issue Description

Need to remove coverage for cervical and thoracic epidural blocks as it will be addressed in the Multi-Jurisdictional MACs policy Epidural Steroid Injections for Pain Management LCD and the associated Billing and Coding Epidural Steroid Injections for Pain Management LCA effective 6/19/2022.


CMS National Coverage Policy

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

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

PUB 100-03 Medicare National Coverage Determinations (NCD) Manual- Chapter 1 Section:
30.3 – Acupuncture
150.6 - Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc of the Foot
150.7 - Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, 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 three months or more.

Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been established.

• Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered.

• Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may be maintained through the infusion of local anesthetics via indwelling catheter.

Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, 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 or other collaborative comprehensive evaluation.

Imaging guidance with fluoroscopy, CT or ultrasound may be necessary to perform somatic nerve blockade. Only fluoroscopic or CT guidance may be covered for epidural injections.

Provider Qualifications

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 ( states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

Patient safety and quality of care mandate that healthcare professionals who perform Nerve Blocks are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities.


• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.
• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.
• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.


• Radiculopathy and other neurological deficits require further evaluation and management prior to performing the blocks.


This policy does not cover epidural blocks, which are covered in another Noridian policy. Please refer to L39240/A58993.

Summary of Evidence


Analysis of Evidence (Rationale for Determination)


Proposed Process Information

Synopsis of Changes
Changes Fields Changed
In the Coverage Indications, Limitations and/or Medical Necessity, under EPIDURAL BLOCK, removed all coverage for Cervical and Thoracic epidural blocks and referred providers to Noridian's new Epidural Steroid Injections for Pain Management LCD & associated Billing and Coding Epidural Steroid Injections for Pain Management LCA L39240/A58993.

NOTE: Only comments related to this information removed is open for comment from the public. No other coverage within this policy are up for comment at this time.
Coverage Indications, Limitations and/or Medical Necessity
Associated Information

General Information

Please refer to LCD 34218 for coverage criteria for Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma. Access this LCD under Related Local Coverage Documents below.

Utilization Guidelines
Treatment protocols utilizing multiple injections per day on multiple days per week for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases are not considered medically necessary.

A peripheral nerve injection may be allowed during the reconsideration process if the medical record supports a medically necessary service.

Sources of Information

1. Bril V, England J. 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. Neurology. 2011: May 17; 76(20):1758-65. NGC: 008504.

2. Cernak C, Marriot E, et al. Electrical current and local anesthetic combination successfully treats pain associated with diabetic neuropathy: Practical Pain Management; April 2012 online at:

3. Chaudhry V, Stevens JC, et al. Practice advisory: utility of surgical decompression for treatment of diabetic neuropathy: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2006;2:1805-1808.

4. Hamza MA, White PF, Craig WF, et al. Percutaneous Electrical Nerve Stimulation: A Novel Analgesic Therapy for Diabetic Neuropathic Pain. Diabetes Care. 2000: March; 23(3):365-370.

5. Joint section on pain, the American Association of Neurological Surgeons and Congress of Neurological Surgeons.

6. Karmakar MK et al. Thoracic paravertebral block for management of pain associated with multiple fractured ribs in patients with concomitant lumbar spinal trauma. Reg Anesth Pain Med 2001; 26:169-173

7. Merskey H, Bogduk N. Description of chronic pain syndromes and definitions of pain terms. In: Classification of Chronic Pain, 2nd ed. Seattle, WA: IASP press; 1994.

8. Naja MZ et al. Nerve-stimulator guided paravertebral blockade vs. general anesthesia for breast surgery. Euro J. Anaesth. 2003;20:897-903.

9. Noridian Intermediary Advisory Committee (IAC) on Pain

10. Odell RH, Sorgnard R, New technique combines electrical and local anesthetic for pain management: Practical Pain Management; June 2011: online at>/issue/1106

11. Yale University School of Medicine, Department of Pain Management



Open Meetings
Meeting DateMeeting StatesMeeting Information
05/26/2022 American Samoa
California - Entire State
California - Northern
California - Southern
Northern Mariana Islands


Contractor Advisory Committee (CAC) Meetings
MAC Meeting Information URLs
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
  • Other (Remove coverage of cervical/thoracic epidural blocks due to finalization of the Epidural Steroid Injections for Pain Management LCD and associated LCA.)
Requestor Information
This request was MAC initiated.
Contact for Comments on Proposed LCD
Policya Drafts
Noridian Administrative Services, LLC
P.O. Box 6722
Fargo, ND 58108-6722

Associated Documents

Related National Coverage Documents


  • Nerve block
  • Peripheral
  • Somatic
  • Cervical and Thoracic
  • Pain
  • Epidural

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