CurrentEmblemHealthPolicy MG.MM.ME.64C7

Peripheral Nerve Blocks

This policy defines medical necessity, limitations, exclusions, and coding for peripheral nerve block procedures for diagnostic and therapeutic management of pain conditions for EmblemHealth members.

Policy Summary

PayerEmblemHealth

PolicyPeripheral Nerve Blocks

Policy CodePolicy MG.MM.ME.64C7

Change TypeTemplate migration (non‑material)

Effective DateJun 13, 2025

Next Review DateJun 13, 2025

Key ActionSubmit clinical evidence and an appropriate ICD-10 diagnosis from the policy list when requesting preauthorization or claims review.

SourceLink

POLICY UPDATE CHANGES

Policy content was transferred to an individual company branded template.

3Max injections per site (6 mo)

2Max sites per session

DeniedUltrasound with non-covered injections

Diagnostic & therapeuticCovered purpose

20+ICD-10 codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Peripheral Nerve Blocks

inv-01: Covered Indications

Peripheral nerve blocks are considered medically reasonable and necessary for diagnostic and therapeutic purposes for certain normally temporary conditions when the criteria below are met:

Covered Indications (examples): Peripheral nerve blocks are covered for diagnostic and therapeutic purposes for normally temporary conditions including: classic mononeuritis with nondiagnostic neurodiagnostic studies where selective blockade clarifies diagnosis; diagnostic peripheral nerve blockade when the clinical picture is unclear; peripheral nerve injuries/entrapment or extremity trauma leading to complex regional pain syndrome; occipital nerve block to confirm occipital neuralgia; suprascapular nerve block to confirm suprascapular entrapment; trigeminal nerve block (central or peripheral branches); and injections for Morton's-type plantar digital (plantar common digital nerve) pathology as described.

These examples reflect guideline items; see full policy for the complete list and contextual considerations.

inv-02: Perioperative / Preemptive Analgesia

When used as preemptive analgesia or to control severe post‑surgical pain, these conditions apply:

Perioperative / Preemptive Analgesia: Preemptive analgesia (single-shot or continuous peripheral nerve block) is presumed medically necessary when the surgical procedure is of such nature that the patient would benefit; single injection blocks may be used during transition to oral analgesics or when oral analgesics are inadequate or not tolerated; continuous peripheral nerve blocks may provide extended analgesia (approximately 1–5+ days) for severe post‑operative pain or when parenteral analgesia would otherwise be required.

Documentation that the procedure and clinical circumstances justify preemptive or continuous blockade is required.

inv-03: Coverage conditional on diagnosis annotation

Coverage for a peripheral nerve injection CPT code is conditional on the submitted ICD‑10 diagnosis appearing in the policy's diagnosis list and being annotated as a Covered Indication for that specific CPT code:

Diagnosis-to-CPT mapping rule: The ICD‑10 diagnosis submitted with the claim must be on the policy list and must be annotated as a Covered Indication for the specific injection CPT code billed; diagnoses annotated as 'Non‑Covered Indication' for that CPT code render the procedure not covered.

Providers must match diagnosis to CPT code per the policy annotations; see the ICD‑10 lists for code-specific coverage notes (e.g., CPT 64450 vs 64455).

inv-04: Not Medically Necessary / Non-Covered Indications

Diagnoses explicitly annotated as Non‑Covered Indication for Injection, anesthetic agent; other peripheral nerve or branch (CPT 64450):

Non-covered diagnoses (examples): Multiple ICD‑10 codes in the policy are explicitly flagged as 'Non‑Covered Indication' for CPT 64450 (examples include causalgia and specific mononeuropathy and radiculopathy codes and other listed diagnoses).

See the ICD‑10 diagnosis sections (chunks 88–93) for the full enumerated list and specific per‑code annotations; use of CPT 64450 with diagnoses so annotated is not covered.

There is insufficient evidence to support the use of peripheral nerve blocks for diabetic peripheral neuropathy or for peripheral neuropathies caused by other underlying systemic diseases, degenerative conditions, or idiopathic neuropathies; these uses are considered investigational and are not eligible for coverage. The policy expects signs and symptoms to resolve after 1–3 injections at a specific site; persistent or repeat injections beyond that course should prompt alternative management. (See limitations for additional context on investigational status and appropriate medical management.)

Needling procedures described by CPT codes 20560 and 20561 ("dry needling"/needle insertions without injection) for ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths, and tendon origins/insertions are non‑covered per this policy and should not be billed as peripheral nerve block services.

Injection therapies for tarsal tunnel syndrome (including Baxter's injections) and for Morton's neuroma are described as focal injections of tissue surrounding a localized inflammatory focus rather than traditional peripheral nerve block techniques. When injections target the plantar common digital nerve(s) for Morton's neuroma, CPT 64455 is the designated code and is identified in the policy as the specific procedure for those indications.

The document includes extended lists of ICD‑10 diagnosis codes (malignant neoplasms and related codes) in this section; these entries are presented as diagnosis code listings without additional, explicit medical‑necessity rules in the immediate text window.

This excerpt contains only ICD‑10 diagnosis codes (primary malignant neoplasm and related entries) presented as a code list; no explicit coverage criteria or exclusions are stated within this specific code listing window.

The window shows additional ICD‑10 diagnosis codes (lymphoma and hematologic malignancy examples) listed for claim coding reference. This segment is a diagnosis‑code listing and does not include separate coverage statements.

Several diagnoses within the policy’s ICD‑10 lists are explicitly annotated as a Non‑Covered Indication for Injection when billed with certain peripheral nerve injection CPT codes (notably CPT 64450). Claims for CPT 64450 must be supported by an appropriate ICD‑10 diagnosis that is not annotated as non‑covered for that procedure; otherwise the service may be denied.

Multiple ICD‑10 diagnoses in the policy are expressly labeled as Non‑Covered Indication for Injection, anesthetic agent for CPT 64450. Providers should reference the annotated ICD‑10 list when determining whether CPT 64450 is an appropriate, covered billing choice for a given diagnosis.

Frequency limits apply: more than 3 injections per anatomic site in a 6‑month period will be denied, except in rare documented exceptions. Likewise, if progressive sustained relief is not achieved after repeated injections at the same anatomic site, alternative therapies should be considered.

Use of ultrasound guidance in conjunction with injections that are otherwise non‑covered is also considered not medically necessary and will be denied; ultrasound does not convert a non‑covered injection into a covered service.

Diagnoses flagged as a Non‑Covered Indication for injection (for example, several causalgia and mononeuropathy codes shown in the lists) may result in denial when billed with CPT 64450. Providers should confirm that the ICD‑10 diagnosis submitted is not annotated as non‑covered for CPT 64450 before billing.

Specific ICD‑10 entries in the policy identify certain diagnoses as Non‑Covered Indications for CPT 64450; when those diagnoses are present, CPT 64450 may be considered not medically necessary and subject to denial unless another approved indication and code apply.

Procedure and Diagnosis Codes

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization: Not specified in this section. The policy excerpt does not establish a separate prior authorization requirement for these procedures; submitters should follow the member's benefit plan and any payer-specific prior authorization processes in force for the member's program.

Prior Authorization

Prior Authorization and Diagnosis

Prior authorization and diagnosis: When prior authorization is required by the member's benefit plan, the diagnosis submitted for authorization must correspond to an appropriate ICD-10 code from the policy's diagnosis lists (neoplasm/lymphoma and peripheral nerve/neuropathy code sets).

Conservative Treatments and Adjunct Therapies

Frequency and Session Limits

inv-85: per anatomic site peripheral nerve block — <= 3 injections per anatomic site

Limit≤ 3 injections per anatomic site

PeriodPer 6 months

ApplicationApplies to per anatomic site peripheral nerve block procedures (count by nerve/plexus/branch per CPT description)

inv-86: per session peripheral nerve blocks — <= 2 anatomic sites

Limit≤ 2 anatomic sites per session

ConsequenceMore than 2 sites injected at one session will be denied

Note

Imaging and Guidance Requirements

Note

Imaging not universally required for genicular/neurolytic procedures

Genicular and neurolytic procedure codes (e.g., CPT 64454, 64624) reference imaging guidance when performed, but imaging is not universally required for peripheral nerve blocks in this policy.

If imaging guidance is used, document it; absence of imaging is not by itself a denial trigger for most peripheral nerve block codes.

Note

Imaging note for lymphoma-related diagnosis list

Chunk 54 lists lymphoma and hematologic malignancy ICD-10 codes but does not specify imaging requirements for peripheral nerve injections.

Note

No imaging requirement specified in this ICD-10 segment

Chunk 88 contains extensive ICD-10 diagnosis listings with policy annotations but does not impose imaging prerequisites for authorization or coverage in the excerpt.

Background and Scope

Peripheral nerve blocks may serve either a diagnostic role—to localize the source of neuropathic pain—or a therapeutic role—to provide temporary analgesia. These procedures are generally expected to provide only transient relief; if only temporary benefit is achieved, more definitive neurolytic procedures may be considered as part of long‑term management.

Definitions and Key Terms

inv-71: Peripheral nerve block definition — injection of local anesthetic with/without steroid

DefinitionPeripheral nerve block: injection of local anesthetic with or without steroid to isolate or treat peripheral nerve–related pain; may be diagnostic or therapeutic

PurposeUsed to isolate source of pain diagnostically or to provide temporary therapeutic relief

Next steps if ineffectiveIf sustained relief is not achieved, consider neurolytic procedures (chemical, cryoneurolysis, radiofrequency)

inv-72: Morton's neuroma (generic) — definition used generically for swollen/inflamed nerve in ball of foot

DefinitionMorton's neuroma (generic): used to refer to a swollen/inflamed nerve in the ball of the foot, including Morton's, Heuter's, Hauser's, and Iselin's neuromas

Coding note

Not Covered / Investigational

The policy identifies specific services and indications that are not covered: treatment of diabetic peripheral neuropathy and neuropathies due to systemic disease is investigational and non‑covered; "dry needling" techniques (CPT 20560, 20561) for neuromas or peripheral nerve structures are non‑covered; and the use of ultrasound guidance with injections that themselves are non‑covered is considered not medically necessary and will be denied.

References and Revision History

Note

Operational migration — clinical criteria preserved

This excerpt documents that policy content was transferred to an EmblemHealth branded template; the migration was an operational formatting change and did not introduce new clinical criteria.

Policy Summary

PayerEmblemHealth

PolicyPeripheral Nerve Blocks

Policy CodePolicy MG.MM.ME.64C7

Change TypeTemplate migration (non‑material)

Effective DateJun 13, 2025

Next Review DateJun 13, 2025

Key ActionSubmit clinical evidence and an appropriate ICD-10 diagnosis from the policy list when requesting preauthorization or claims review.

SourceLink

On This Page

Billing Rule

Ensure Diagnosis-to-Procedure Match Before Authorization

Match diagnosis to CPT code before authorization: Providers must ensure the ICD-10 diagnosis on the authorization request and claim maps to the CPT procedure billed. Certain ICD-10 codes in the list are explicitly annotated as Covered Indication (for a specific CPT) or Non-Covered Indication (for a specific CPT); claims or authorizations that do not match the documented diagnosis-to-procedure mapping risk denial.

Ensure mapping of ICD-10 → CPT (e.g., tarsal tunnel codes annotated as Covered only for CPT 64450 in specific entries).
Do not submit a CPT 64450 authorization/claim with an ICD-10 marked as Non-Covered for that CPT.

Note

Prior Authorization Note

Prior authorization note: Content in this excerpt was migrated to the company-branded template; no new payer-wide prior authorization rules are added in the excerpt. Follow program-specific prior authorization procedures where applicable.

Documentation Required

Clinical Documentation Required

Clinical documentation requirement: The treating physician or primary care provider must submit clinical evidence demonstrating the member meets the policy criteria. Without this documentation EmblemHealth cannot properly review preauthorizations or conduct post-payment review.

Include clinical notes, relevant imaging or diagnostic test results, prior treatment history, and documentation of response to prior injections when applicable.

Documentation Required

Preemptive Analgesia — Documentation

Preemptive analgesia documentation: When blocks are used as preemptive analgesia, documentation must support that the surgical procedure is of a nature expected to benefit from preemptive analgesia. A presumption of medical necessity is made only when the procedure and supporting clinical evidence justify preemptive use.

Document surgical indication, expected severity of postoperative pain, and rationale for peripheral nerve block as preemptive analgesia.

Denial Risk

Ultrasound Guidance Denial Risk

Ultrasound guidance denial risk: Use of ultrasound guidance in conjunction with injections that the policy considers non-covered will be treated as not medically necessary and will result in denial.

If an injection itself is non-covered under the policy, any ultrasound-guided variant will also be denied.

Denial Risk

Frequency and Multiple-Site Limits

Frequency limit denial risk: More than 3 injections at the same anatomic site within a 6-month period will be denied (rare exceptions require appropriate documentation). More than 2 anatomic sites injected in a single session will be denied.

Limit: ≤ 3 injections per anatomic site per 6 months (exceptions require documentation).
Limit: ≤ 2 anatomic sites injected per session.

Denial Risk

Missing or Incorrect Diagnosis Code Risk

Missing or incorrect diagnosis code: Claims lacking an appropriate ICD-10 diagnosis from the policy's listed diagnosis codes (neoplasm/lymphoma sets and peripheral nerve/neuropathy lists) may be denied. Providers must supply the appropriate ICD-10 code from the policy list when submitting claims and documentation.

Denial Risk

Non-Covered Diagnosis-Code Triggers

Non-covered diagnosis-code triggers: Several ICD-10 entries are explicitly annotated in the list as Non-Covered Indications for specific injections (marked with an asterisk in the source). Using those diagnoses with the corresponding CPT will trigger a non-covered determination.

Examples: codes annotated with "Non-Covered Indication for Injection, anesthetic agent; other peripheral nerve or branch, CPT code 64450" will not support coverage for CPT 64450.

Billing Rule

Covered Only for Specific Procedure

Covered-only-for-specific-procedure: Some diagnoses in the ICD-10 list are annotated as Covered Indication only for a specific CPT code (examples include certain tarsal tunnel and Morton's neuroma codes tied to CPT 64450 or CPT 64455). These diagnoses should only be used when billing the indicated CPT.

Example: select tarsal tunnel and plantar nerve lesion codes are annotated as Covered Indication only when billed with the specified CPT (e.g., CPT 64450 or 64455 as noted).

Denial Risk

Denial Risks from Incorrect Diagnosis-to-CPT Mapping

Denial risks tied to diagnosis-code mapping: CPT 64450 and other peripheral nerve injection CPTs have explicit denial risk when billed with ICD-10 codes annotated as Non-Covered or as not indicated for that procedure. Verify the policy's ICD-10 annotations before submitting claims or authorization requests to avoid denial.

Confirm the ICD-10 on the claim is not marked Non-Covered for the billed CPT.
For CPT 64450, avoid pairing it with codes annotated as Non-Covered Indication for that CPT.

Note

ICD-10 Diagnosis Code Lists Provided

The document provides ICD-10 diagnosis codes: The policy includes extensive ICD-10 diagnosis code lists for neoplasms, lymphomas, multiple myeloma/plasmacytoma, peripheral neuropathies and other relevant conditions. Use these lists to select the appropriate diagnosis code when requesting authorization or submitting claims.

Providers must supply an ICD-10 from these lists on claims and documentation tied to neoplasm/lymphoma services and peripheral nerve injection services.

Billing Rule

Diagnosis Coding on Claims and Documentation

Diagnosis Coding Requirement and Claims: When submitting claims for services referenced in this policy, include the specific ICD-10 diagnosis code from the applicable policy list. Diagnosis-to-procedure linkage must be documented in the medical record and on the claim.

Include the ICD-10 code on the claim and in clinical documentation.
Ensure the clinical record supports the diagnosis billed and its linkage to the procedure performed.

Documentation Required

Documentation Requirement for CPT 64450

Documentation for CPT 64450: Claims or authorization requests for CPT 64450 must be supported by an appropriate ICD-10 diagnosis from the policy's list that is not marked as a Non-Covered Indication for that CPT. Specific diagnoses in the list are annotated as Covered or Non-Covered for CPT 64450 — follow those annotations.

Do not bill CPT 64450 with ICD-10 codes explicitly marked Non-Covered for that CPT.
When billing CPT 64450, document clinical rationale, prior treatments, and response to prior injections if applicable.

If relief is not achieved after 2–3 repeats at same site, alternative therapies should be explored

inv-87: Frequency placeholder (chunk 54)

Frequency infoChunk 54 lists lymphoma/hematologic ICD-10 codes; no explicit frequency limit specified in this window

Provider instructionApply policy frequency limits (e.g., ≤3 injections per site/6 months) when procedures are performed for these diagnoses unless otherwise noted

DocumentationWhen exceptions are claimed, provide clinical documentation supporting more frequent interventions

inv-88: Frequency placeholder (chunk 88)

Frequency infoChunk 88 contains ICD-10 lists and annotated coverage status but does not specify additional frequency thresholds

InstructionUse the policy’s standard frequency limits for procedures tied to these diagnoses unless explicit exceptions are documented

Provider actionEnsure appropriate ICD-10-to-procedure mapping per annotations when requesting authorization or submitting claims

inv-89: Injection, anesthetic agent; other peripheral nerve or branch (CPT 64450) — frequency/coverage context

ProcedureCPT 64450 — Injection, anesthetic agent; other peripheral nerve or branch

Coverage contextUse of CPT 64450 must be supported by an appropriate ICD-10 diagnosis from the policy list; several diagnoses are explicitly noted as Non-Covered for 64450

FrequencyApply policy frequency limits (≤3 injections per anatomic site/6 months; ≤2 sites per session) when billing CPT 64450

Note

References do not mandate imaging requirements

The policy references evidence reviews and guidelines relevant to interventional pain procedures but does not specify imaging requirements in those references.

Policy references CPT 64455 for injections of plantar common digital nerves (eg, Morton's neuroma)

Clinical contextTerm is applied generically across similar plantar nerve lesion presentations for guidance consistency

inv-73: ICD-10 Diagnoses — sequential list presented as acceptable/related codes

ContentSequential ICD-10 lists include malignant neoplasm blocks (examples: C34.x, C37, C38.x, C39.x) and central nervous system neoplasm codes (C70.x–C74.x)

UseThese ICD-10 codes are included as acceptable/related diagnoses for claims and mapping to procedure codes in the policy

Provider actionSelect the specific ICD-10 code from the policy list when submitting documentation or authorization requests

inv-74: Malignant neoplasm codes — ICD-10 codes starting with 'C' mapping

RangePrimary malignant neoplasm codes (C-series) are listed; secondary malignant neoplasm blocks include C77–C79 ranges

ExamplesSecondary neoplasm examples: C78.7 (liver), C79.31 (brain), C79.32 (cerebral meninges)

ImplicationThese secondary malignant neoplasm codes are part of the policy’s ICD-10 lists for diagnosis mapping

inv-75: Secondary malignant neoplasm codes — C77-C79 range

RangeSecondary malignant neoplasm codes include C77–C79 series (examples in chunks list metastases to nodes, lung, liver, brain)

ExamplesC77.x (lymph nodes), C78.x (secondary respiratory/pleural), C79.x (secondary sites including brain, bone, breast)

UseIncluded in policy ICD-10 lists for coding and claims linkage when applicable

inv-76: ICD-10 Diagnoses list — comprehensive partial list covering malignant/benign neoplasms, leukemias, lymphomas

ScopeComprehensive partial ICD-10 list covers malignant neoplasms, leukemias, lymphomas and related hematologic malignancies (examples: C83.x, C90.x, C91.x)

ExamplesMantle cell lymphoma (C83.12–C83.19), diffuse large B-cell lymphoma (C83.30–C83.38), multiple myeloma (C90.00–C90.02)

Provider actionUse specific listed ICD-10 descriptors from these sections when claims are submitted for related procedures

inv-77: Policy-annotated diagnosis — diagnoses marked with asterisk indicate coverage status for injections

Annotation meaningDiagnoses marked with an asterisk or accompanying text indicate coverage designation (e.g., Covered Indication or Non-Covered Indication for specific CPT codes)

ImpactIf a diagnosis is annotated as Non-Covered for a CPT code, that procedure will be considered not medically necessary for that diagnosis

Provider actionMatch the submitted ICD-10 diagnosis and its policy annotation to the CPT code billed to avoid denial

inv-78: Non-Covered Indication — diagnosis explicitly called non-covered for Injection, anesthetic agent; other peripheral nerve

DefinitionNon-Covered Indication: a diagnosis explicitly called out as not covered for Injection, anesthetic agent; other peripheral nerve or branch (CPT 64450)

ExamplesMultiple causalgia and mononeuropathy codes (e.g., G56.41–G56.43, G57.71–G57.73, G57.91–G57.93, G57.92) are noted as Non-Covered for CPT 64450 in the list

ConsequenceUse of CPT 64450 with an ICD-10 listed as Non-Covered Indication may be denied as not medically necessary