Intraoperative peripheral nerve blocks — code with primary procedure

If peripheral/ganglion nerve blocks are performed intraoperatively or “as part of a surgery or other procedure,” code them with the primary surgical/procedural code and do not bill them separately for prior authorization or separate payment.

• Follow proper coding practices: include the block in the primary procedure claim rather than submitting a separate PA request for the block.

Prior authorization may be required for referenced neurolysis/ablation CPT codes

Certain neurolysis and ablation CPT codes referenced in the policy may require prior authorization per payer rules; providers should verify PA requirements for these codes before scheduling services.

• Examples of referenced neurolysis/ablation codes include 64628, 64629, 64624, 64620, 64680, and 64454 (policy lists CPTs that may be subject to PA).
• Inclusion in the policy does not replace payer-specific PA rules—confirm with the Health Plan prior to service.

Check Health Plan administrative policies and benefits for PA requirements

Prior authorization requirements are governed by the Health Plan’s administrative policies and the member’s benefit documents; providers must check PA requirements before performing services.

• Verify plan-specific PA rules and benefit limits prior to service.
• State Medicaid or Medicare NCD/LCD requirements may supersede this policy—review those rules when applicable.

Conservative therapy must be documented prior to therapeutic blocks

Therapeutic occipital and celiac plexus procedures require documented failure of prior conservative therapy before proceeding with therapeutic injections or neurolysis.

• Occipital therapeutic blocks: documentation of failed 3 months of conservative treatment (heat/rest/PT, NSAIDs unless contraindicated, oral anticonvulsant or tricyclic antidepressant therapy, and activity modification).
• Celiac plexus: used when opioids are no longer effective or intolerable; chronic pancreatitis indication requires prior refractory therapy and, for repeat blocks, ≥3 months since prior injection with documented clinical benefit.

Document provider-level procedural requirements before authorization/claim

Ensure all procedure-specific provider actions and requirements in this policy are documented in the medical record before requesting authorization or submitting claims.

• Document that procedures were performed by appropriately trained clinicians when relevant (e.g., sympathetic blocks managed by pain specialists for CRPS).
• Follow coding guidance when blocks are performed with or as part of another procedure.

Administrative reminder — confirm coding, contracts, and guidance

Administrative reminders: confirm coding matches clinical indication and that claims follow plan/provider contract terms.

• Reference current CPT descriptions and professional coding guidance prior to claim submission.
• Claims submission must comply with the Health Plan contract and benefit terms.

Occipital block — required clinical documentation elements

Occipital nerve block documentation must include pain distribution and characteristics, evidence of dysesthesia/allodynia and either tenderness or a trigger point, and for therapeutic blocks record prior temporary relief and three months of failed conservative therapy.

• Document unilateral or bilateral pain in the distribution of greater/lesser/third occipital nerves and at least two characteristic features (e.g., severe intensity, shooting/stabbing quality).
• For therapeutic blocks, record numeric pain reduction after prior injection and failure of the 3-month conservative therapy regimen listed in the policy.

Sympathetic block — required documentation for CRPS

For sympathetic nerve blocks in CRPS, document diagnosis, management by an experienced pain specialist, active rehabilitation, failure of ≥3 weeks of conservative therapies, and two or more objective findings in the affected extremity.

• Objective findings include hyperalgesia/allodynia; edema or sweating changes/asymmetry; temperature asymmetry >1°C or skin color changes; decreased ROM, motor dysfunction, or trophic changes.
• Additional sympathetic blocks require documentation of immediate positive response to the first or second block and blocks given at least one week apart.

Celiac plexus block/neurolysis — required documentation elements

For celiac plexus block/neurolysis for pancreatic cancer or chronic pancreatitis, document diagnosis, severity of visceral abdominal/back pain, and that opioids are ineffective or not tolerated (for cancer); for chronic pancreatitis document nondilated duct and prior response if repeat is requested.

• Pancreatic cancer indication: diagnosis of pancreatic cancer with severe visceral abdominal/back pain and opioid ineffectiveness or intolerability; exclude somatic malignancy in related innervation areas.
• Chronic pancreatitis indication: refractory pain with non-dilated pancreatic duct; repeat block allowed only if ≥3 months since prior injection and there was clinical benefit.

Document prior block response and include CPT codes for repeat groin blocks

For post-herniorrhaphy groin pain, document the patient’s positive response to the initial diagnostic block and include the CPT code(s) used when requesting repeat therapeutic blocks.

• Include examples of CPTs used (policy examples: 64420–64421 for intercostal nerve, 64450/64454 for peripheral nerves) and note injections may be given every 1–3 weeks while relief is developing.
• Document imaging ruled out non‑neuropathic causes and that less invasive methods failed prior to the first diagnostic block.

Align documentation and claims with policy, benefit terms, and external rules

Ensure clinical documentation and coding align with this clinical policy, the member’s benefit terms, and any applicable state Medicaid or Medicare NCD/LCD requirements when submitting claims.

• When state Medicaid or Medicare rules conflict with this policy, those rules take precedence; review applicable NCDs/LCDs prior to applying policy criteria.
• Align submitted CPT codes and clinical notes to support medical necessity under the Health Plan’s benefit terms.

Denial risk — additional sympathetic blocks without documented benefit

Additional sympathetic nerve blocks without documented benefit from the first or second block are considered not medically necessary and may be denied.

• Additional blocks must be given at least one week apart and require an immediate positive response to the first or second block (e.g., improved temperature ≥1.5°C and decreased pain) to be considered medically necessary.

Denial risk — repeat celiac plexus procedures without specified indications

Repeat celiac plexus nerve blocks or neurolysis for indications other than the specified pancreatic cancer or chronic pancreatitis criteria are not medically necessary and may be denied.

• Repeat neurolysis is discouraged for unspecified indications due to low effectiveness; repeat chronic pancreatitis blocks allowed only when ≥3 months since prior injection and clinical benefit was documented.

Coding listed in policy does not guarantee coverage

Inclusion or exclusion of CPT codes in this policy is informational only and does not guarantee coverage; providers should reference up-to-date coding guidance prior to claim submission.

• CPT codes and descriptions are provided for informational purposes; always verify current professional coding guidance and payer rules before billing.

Denial triggers — benefit limits and external coverage rules may override policy

Coverage and denial decisions are subject to the Health Plan’s benefit terms, exclusions and limitations, administrative policies, and applicable state or Medicare coverage rules; discrepancies defer to those governing requirements.

• Review the member’s evidence of coverage and plan-level administrative procedures prior to treatment.
• For Medicare members, applicable NCDs/LCDs and Coverage Articles should be reviewed before applying policy criteria.

Imaging optional for general invasive pain management procedures

Imaging guidance is optional for many invasive pain management procedures; the policy allows procedures with or without radiographic guidance and permits only one procedure per visit.

• Policy states procedures may be performed with or without radiographic guidance and that the patient receives only one procedure per visit.

Recommend imaging guidance for intercostal, peripheral nerve injections, and neurolysis when specified

Ultrasound or radiologic monitoring is recommended when performing intercostal nerve blocks, peripheral nerve injections, and neurolysis where CPT descriptions specify imaging to minimize complications and improve dermatomal coverage.

• Intercostal blocks can be performed with ultrasound guidance to reduce intravascular injection and pneumothorax risk and to increase reliable dermatomal coverage.
• Many CPT codes include imaging guidance when performed.

Refer to cited guidelines and LCDs for any additional imaging or technique requirements

Cited clinical guidelines and CMS Local Coverage Determinations or articles referenced in the policy may include additional imaging or technique requirements; refer to those sources and the policy's referenced LCDs for specifics.

• Review the referenced guidelines and LCDs for procedure-specific imaging or technique stipulations that may apply to Medicare members.