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Local Coverage Determination (LCD)

Peripheral Nerve Blocks

L33933

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Proposed LCD
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Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33933
Original ICD-9 LCD ID
Not Applicable
LCD Title
Peripheral Nerve Blocks
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/08/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

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

CMS National Coverage Policy

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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.
Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
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Contractor Advisory Committee (CAC) Meetings
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This request was MAC initiated.
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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

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 Group 1 Codes:

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

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Group 1

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

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.
Sources of Information

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.
Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
01/08/2019 R10

Revision Number: 7
Publication: November Year Connection
LCR B2019-031

Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act and IOM reference sections were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018.

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 LCD.
  • Other (Revision based on CR 10901)
11/06/2018 R9

Revision Number: 6
Publication: November 2018 Connection
LCR B2018-019

Explanation of Revision: Based on an annual review of the LCD, it was determined that some of the italicized language in the “Coverage Indications, Limitations, and/or Medical Necessity” section of the LCD under “Indications” does not represent direct quotation from the CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. In addition, the “Sources of Information” section of the LCD was updated to include the published CMS source. The effective date of this revision is based on date of service.

110/06/2018:  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 LCD.
  • Other (Revisions based on annual review completed on 09/26/2018.)
10/01/2018 R8

Revision Number: 5

Explanation of Revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised to indicate that diagnosis codes were added and deleted within existing diagnosis code ranges. The effective date of this revision is based on date of service.
  • Revisions Due To ICD-10-CM Code Changes
03/15/2018 R7

Revision Number: 4

Publication: March 2018 Connection

LCR B2018-009

Explanation of Revision:  Based on an annual review of the LCD, it was determined that some of the italicized language in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD does not represent direct quotation from the CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service.

03/15/2018:  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 (Revisions made based on an annual review completed on 12/27/2017.)
10/01/2017 R6

Revision Number: 3

Publication: September 2017 Connection

LCR B2017-011

Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Changed ICD-10-CM diagnosis code range D47.0-D47.1 to D47.01-D47.1. Deleted ICD-10-CM diagnosis code D47.0. The effective date of this revision is based on date of service.

 

10/01/2017:  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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R5 RRevision Number: 2 Publication: October 2016 Connection
LCR B2016-097

Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. ICD-10-CM diagnosis codes D47.Z1and D47.Z9 were listed singly in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT codes 64400, 64402, 64405, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, 64449, and 64450. The following diagnoses code ranges in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT codes 64400, 64402, 64405, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, and 64449 were revised: range G56.00 - G56.02 was revised to read G56.00 - G56.03, range G56.40 - G56.42 was revised to read G56.40 - G56.43, range G57.10 - G57.12 was revised to read G57.10 - G57.13, range G57.70 - G57.72 was revised to read G57.70 - G57.73, and range G57.90 - G57.92 was revised to read G57.90 - G57.93. Also, the following diagnoses code ranges in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT code 64450 were revised : range G56.00 - G56.02 was revised to read G56.00 - G56.03, range G57.10 - G57.12 was revised to read G57.10 - G57.13 and range G57.50 - G57.52 was revised to read G57.50 - G57.53. In addition, the following diagnosis code range in the “ICD-10 Codes that Support Medical Necessity” section of the LCD for CPT code 64455 and the note below this section was revised: Range G57.60 - G57.62 was revised to read G57.60 - G57.63. The effective date of this revision is based on date of service.
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R4 Revison Number: 1
Publication: December 2015 Connection
LCR B2016-003

Explanation of Revision: Annual 2016 HCPCS Update. CPT code 64412 was deleted. The effective date of this revision is based on date of service.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R3 07/15/15- The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 07/15/15- The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 03/04/15 - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
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Associated Documents

Attachments
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Related Local Coverage Documents
Articles
A57788 - Billing and Coding: Peripheral Nerve Blocks
Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
11/22/2019 01/08/2019 - N/A Currently in Effect You are here
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