Local Coverage Determination (LCD)

Nerve Blockade for Treatment of Chronic Pain and Neuropathy

L35457

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Contractor Information

LCD Information

Document Information

LCD ID
L35457
LCD Title
Nerve Blockade for Treatment of Chronic Pain and Neuropathy
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL35457
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/04/2022
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
07/21/2022
Notice Period End Date
09/03/2022
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Issue

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.

Issue - Explanation of Change Between Proposed LCD and Final LCD

No Comments received within the specified Comment Period. No changes made to this Final LCD from the Proposed LCD.

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. It is inappropriate to bill for fluoroscopy (CPT® codes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPT® description of the procedure(s) performed.

Provider Qualifications

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) 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.

PERIPHERAL NEUROPATHY

• 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.

SOMATIC NERVE BLOCK

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

EPIDURAL BLOCK (Cervical and Thoracic)

This policy does not cover epidural blocks, which are covered in another Noridian policy. Please refer to L39242/A58995.

Summary of Evidence

NA

Analysis of Evidence (Rationale for Determination)

NA

General Information

Associated Information

General Information

Please refer to LCD 34076 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:
http://www.practicalpainmanagement.com/issue/1203

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 http://www.practicalpainmanagement.com>/issue/1106

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

Bibliography

NA

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
09/04/2022 R18

No Comments received within the specified Comment Period. No changes made to this Final LCD from the Proposed LCD.

  • Other (No Comments received within the specified Comment Period. No changes made to this Final LCD from the Proposed LCD.)
02/03/2022 R17

Under General Information removed the broken link to LCD 34076 - Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma and added the sentence “Access this LCD under Related Local Coverage Documents below.”

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.

  • Typographical Error
12/01/2019 R16

The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of 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.

  • Other (The LCD is revised to remove CPT/HCPCS codes in the Keyword Section of the LCD.
    )
12/01/2019 R15

As required by CR 10901, all billing and coding information has been moved to the companion article; this article is linked to 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.

  • Revisions Due To Code Removal
01/01/2019 R14

The LCD revised to remove deleted CPT code 64508 in Group 1 effective 1/1/2019.

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 in the LCD are applicable as noted in this policy.

 

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R13

6/25/18-At this time 21st Century Cures Act will apply to new and revised LCD's 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.

No change in coverage made for this LCD. Approved addition of Annual Review Date to relate LCD to Local Coverage Article A56034 Peripheral Nerve Blocks Non-covered for the Treatment of Diabetic Peripheral Neuropathic Pain.

  • Other (Approve Annual Review Date to relate LCD to a LCA.)
10/01/2017 R12

02/12/2018-At this time 21st Century Cures Act will apply to new and revised LCD's 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.

Removed 64455 & 64632 with DX codes G56.01-G56.03, G57.51-G57.53 and G57.61-G57.63 as coverage criteria is explained in LCD L34076. Removed duplicate diagnosis codes from the ICD-10 Codes that DO NOT Support Medical Necessity section which are listed in the Group 1 Asterisk section and noted as non-covered when billed with Group 2 CPT codes.

  • Provider Education/Guidance
  • Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2017 R11

01/16/18-At this time 21st Century Cures Act will apply to new and revised LCD's 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.

Clarified it is inappropriate to bill for fluoroscopy (CPT® codes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPT® description of the procedure(s) performed under Coverage Indications, Limitations and/or Medical Necessity

  • Provider Education/Guidance
  • Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2017 R10

08/24/2017: 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.

Effective DOS 10/01/2017 the following ICD-10-CM codes were added or deleted:

Added:

  • M48.062

The following ICD-10 codes were deleted from the ICD-10 Codes that Support Medical Necessity field:
M48.06 was deleted from Group 1

  • Revisions Due To ICD-10-CM Code Changes
01/01/2017 R9 LCD revised to add CPT codes 62320, 62321, 62324 and 62325 to Group 1 effective 01/01/2017. No change in coverage has been made.

CPT codes 62310 and 62318 were are deleted from Group 1 effective 12/31/2016
  • Creation of Uniform LCDs Within a MAC Jurisdiction
  • Revisions Due To CPT/HCPCS Code Changes
11/10/2016 R8 This final LCD, effective 11/10/2016, combines JFA L35458 into the JFB L35457 LCD so that both JFA and JFB contractor numbers will have the same final MCD LCD number L35457. Coverage will remain the same as the coverage effective 10/01/2016.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2016 R7 The LCD is revised to add the new ICD-10 codes effective 10/1/2016: G56.03, G56.13, G56.23, G56.33, G56.43, G56.92, G57.03, G57.13, G57.23, G57.33, G57.43, G57.53, G57.63*, G57.73, M50.121, M50.122, M50.123, M50.221, M50.222, M50.223, M50.321, M50.322 and M50.323.

The following ICD-10 codes were deleted from Group 1 effective 10/1/2016: M50.12, M50.22, M50.32.

The following ICD-10 code descriptions were changed effective 10/1/2016 in Group 1: S54.8X1A, S54.8X1D, S54.8X1S, S54.8X2A, S54.8X2D, S54.8X2S.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R6 R6 LCD revised to add ICD-10-CM codes R10.11-R10-13, R10.31-R10.33 & asterisks to ICD-10-CM codes G57.91-G57.92 in the Group 1 ICD-10 codes that Support Medical Necessity. Add G57.91-G57.92 codes to the Group 1: Medical Necessity ICD-10 codes Asterisk Explanation, added G57.91-G57.92 to the Group 1 Paragraph & list of Codes in the ICD-10-CM Codes that DO NOT Support Medical Necessity section. Also added the following statements: CPT codes 64450 or 64640 may not be billed with diagnosis G57.61 and G57.62. The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma to Group 1 Paragraph in the CPT/HCPCS Code Section; and G57.61, G57.62 - The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma. CPT codes 64450 or 64640 may not be billed with diagnosis G57.61, G57.62 to the Group1: Medical Necessity ICD-10 Codes Asterisk Explanation.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
01/01/2016 R5 R5 - Clarified when duplicated ICD-10-CM codes G58.7, G58.8, G58.9 G59, M54.10 and M79.2 are allowed and denied in Group 2 Paragraph, Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation and Group 1 Paragraph in the ICD-10 Codes that DO NOT Support Medical Necessity
  • Other (Clarification of when duplicated ICD-10 codes are allowed and denied when billed with 64450.)
01/01/2016 R4 R4 LCD revised to add CPT codes 64461-64463 to Group 1 of the CPT/HCPCS Codes section and the following CPT/HCPCS codes were deleted: 64412 was deleted from Group 1 per 2016 CPT/HCPCS update.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R3 LCD revision expands coverage to include codes with the 7th character extender “S” for S14, S24, S34, S44, S54, S64, S74, S84 and S94 codes that are currently listed in the policy as covered with “A” & “D” character extenders.
  • Other (Expansion of coverage to include codes with the 7th character extender “S” for S14, S24, S34, S44, S54, S64, S74, S84 and S94 codes that are currently listed in the policy as covered with “A” & “D” character extenders.)
10/01/2015 R2 The LCD is revised to add the sentence "CPT code 64450 may not be billed with diagnosis G57.61, G57.62. The correct CPT procedure code is 64455 when billing for the diagnosis of Morton’s Neuroma" in the CPT/HCPCS section and the "Medical Necessity ICD-9 Codes Asterisk Explanation" for Group 1.
  • Risk Identified by the Office of Inspector General (OIG)
10/01/2015 R1 This LCD is revised to reflect corrections made to the ICD-9 version.
  • Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
07/14/2022 09/04/2022 - N/A Currently in Effect You are here
02/09/2022 02/03/2022 - 09/03/2022 Superseded View
01/29/2020 12/01/2019 - 02/02/2022 Superseded View
11/19/2019 12/01/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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

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