CurrentCentenePolicy MC.CP.MP.170

Peripheral Nerve Blocks

Defines medical necessity, non-coverage, and investigational/insufficient evidence criteria for peripheral nerve blocks (diagnostic and therapeutic) for Medicare health plans affiliated with Centene, and lists applicable CPT codes and coding/billing guidance.

Policy Summary

PayerCentene

PolicyPeripheral Nerve Blocks

Policy CodePolicy MC.CP.MP.170

Change TypeAnnual review; added genicular nerve block guidance; coding clarification

Effective Date

Next Review Date

Key ActionDocument the diagnostic reason aligning with the listed medically necessary indications and bundle peripheral/ganglion nerve blocks with a surgery/procedure when administered as part of that procedure.

SourceLink

POLICY UPDATE CHANGES

Added criteria III.B. regarding genicular nerve blocks and neurolysis (insufficient evidence) in 02/24 and 04/24 revisions.

Added note that if nerve block is administered as part of surgery/other procedure, coding should follow proper coding practices and would not be subject to prior authorization or separate payment.

Annual reviews recorded with revision and approval dates in 08/23, 02/24, and 04/24.

>=3Allowed injections per anatomic site (6 months)

>2Anatomic sites per session (not allowed)

Insufficient

Coverage Summary

This policy defines medical necessity, non-coverage, and investigational/insufficient evidence criteria for peripheral nerve blocks (PNBs) for Medicare health plans affiliated with Centene. Peripheral nerve blocks are used for both diagnostic and therapeutic purposes — for example, to isolate a nerve as the source of pain or to provide analgesia during transitions in pain management or when oral/standard therapies are not effective.

Coverage stance: mixed. Primary intended uses include diagnostic purposes (e.g., confirming occipital, suprascapular, or trigeminal nerve-related pain; clarifying unclear clinical pictures; evaluating suspected mononeuritis) and therapeutic purposes (e.g., preemptive analgesia to avoid general anesthesia and to spare opioid use).

Policy thresholds and quick limits

Maximum injections per anatomic site<= 3 injections in a six-month period

Maximum anatomic sites per session<= 2 anatomic sites per session

Genicular nerve blocks statusInsufficient evidence / Not supported (investigational) for treatment of knee osteoarthritis

Medical-Necessity Criteria

Medically Necessary

Peripheral nerve blocks will be considered medically reasonable and necessary for the following diagnostic and therapeutic purposes:

ALL of the following

Diagnostic/Therapeutic indications
- When pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation
- When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome
- When selective peripheral nerve blockade is used diagnostically in cases in which the clinical picture is unclear
- When an occipital nerve block is used to confirm the clinical impression of the presence of occipital neuralgia

Coding

Applicable CPT codes (informational; inclusion/exclusion does not guarantee coverage)CPT

20560	Needle insertion(s) without injection(s); 1 or 2 muscle(s)
20561	Needle insertion(s) without injection(s); 3 or more muscles
64400	Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)
64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve
64415	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed
64416	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement), including imaging guidance, when performed
64417	Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed
64418	Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve
64420	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level
64421	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (list separately in addition to code for primary procedure)

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1/3

Note: If a peripheral/ganglion nerve block is administered as part of a surgery or other procedure, coding should follow proper coding practices and the nerve block would not be subject to separate prior authorization or separate payment; it should be bundled with the procedure as appropriate.

Provider Actions

Documentation Required

Indication documentation

Document diagnostic reason aligning with one of the medically necessary indications (for example: mononeuritis without structural explanation, complex regional pain syndrome after peripheral nerve injury/entrapment, diagnostic blockade to clarify an unclear clinical picture, occipital/suprascapular/trigeminal nerve diagnostic blocks).

Billing Rule

Bundling with procedures/surgery

If the peripheral/ganglion nerve block is performed as part of a surgery or other procedure, do not submit the nerve block for separate prior authorization or separate payment; follow proper coding practices and bundle the service with the procedure when appropriate.

do not submit for separate prior authorization or separate payment when bundled with procedure

Background & Evidence

This policy is sourced from Centers for Medicare & Medicaid Services Local Coverage Determinations (L33933, L36850) and randomized controlled trials. Reported benefits of peripheral nerve blocks include avoidance of respiratory suppression and other complications of general anesthesia and provision of analgesia while minimizing opioid use. Reported risks include nerve injury, hematoma, local anesthetic systemic toxicity, allergic reaction, infection, myotoxicity, and secondary injury. Evidence specific to genicular nerve blocks is described as very low quality and shows inconsistent benefit for pain and function; safety appears acceptable but benefits and long-term effectiveness over standard therapies are not established.

Source	Summary
Hayes HTA (Genicular nerve block for knee OA)	Published Dec 7, 2023; concludes insufficient established benefit
Randomized trials	Mixed/low-quality evidence for genicular nerve blocks; safety acceptable but inconsistent pain/function benefit

Dry needling: Needling of ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths and their origins/insertions; specifically listed as non-covered in this policy.

Medicare Determinations

Document Type	Number	Name	Effective / Revised Dates
LCD	L36850	Peripheral nerve blocks	2017-05-01 (revised 2019-11-21)
LCD	L33933	Peripheral nerve blocks	2015-10-10 (revised 2019-10-08)
Article	A57452 / A57788	Peripheral nerve blocks

Revision History

02/24added

Added criteria III.B. regarding genicular nerve blocks and neurolysis (insufficient evidence).

04/24added

Added criteria III.B. regarding genicular nerve blocks and neurolysis (insufficient evidence).

02/24clarified

Added note that if nerve block is administered as part of surgery/other procedure, coding should follow proper coding practices and would not be subject to prior authorization or separate payment.