Peripheral Nerve Blocks
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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.
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.
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).
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
- When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve
- When the trigeminal nerve is blocked centrally at the trigeminal ganglion, along one of the three divisions or at one of the peripheral terminal branches (e.g., supraorbital nerve)
Nerve block as preemptive analgesia when a single injection provides post-surgical pain control and one of the following is true
- During the transition to oral analgesics
- In procedures which cause severe pain normally uncontrolled by oral analgesics
- In cases otherwise requiring control with intravenous or parenteral narcotics
- In cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects
- Note: If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure
Not Medically Necessary
The following are considered not medically necessary:
ALL of the following
- Frequency and site limits: 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<= 3 injections in a six-month period
- More than two anatomic sites (e.g., specific nerve, plexus or branch as defined by the CPT code description) injected at any one session<= 2 anatomic sites per session
- Dry needling: "Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths and their origins/insertions, or any tissue are non-covered procedures
Insufficient Evidence / Not Supported (Investigational)
There is insufficient evidence to support the use of peripheral nerve blocks for the following indications:
ALL of the following
- Neuropathy indications: Treatment of diabetic peripheral neuropathy, peripheral neuropathies caused by other underlying systemic diseases, or peripheral neuropathies caused by degenerative or idiopathic reasons
- Genicular nerve blocks/neurolysis: Genicular nerve blocks and neurolysis for the treatment of knee osteoarthritis
- Electrostimulation-related: 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
Coding
| 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) |
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
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).
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
Limits on frequency and sites
Claims that exceed the frequency or site limits are considered not medically necessary and may be denied.
- >3 injections per anatomic site in 6 months
- >2 anatomic sites per session
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
Added criteria III.B. regarding genicular nerve blocks and neurolysis (insufficient evidence).
Added criteria III.B. regarding genicular nerve blocks and neurolysis (insufficient evidence).
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.
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.
Policy developed; annual/periodic updates and reference updates performed.
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