CurrentUniversity Health Alliance (HSA)Policy MPP-0139-220315
Peripheral (Regional) Nerve Block Reimbursement
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Defines University Health Alliance (UHA) reimbursement coverage, limitations, and administrative rules for peripheral (regional) nerve blocks for surgical and pain management indications affecting UHA members and providers submitting claims.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyPeripheral (Regional) Nerve Block Reimbursement
Policy CodePolicy MPP-0139-220315
Change TypeNo material changes
Effective DateJun 16, 2025
Last ReviewJun 16, 2025
Next Review DateN/A
Key ActionPrior authorization is not required.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
25+medically necessary indications
47+investigational/non-covered indications
No prior authprior authorization
≤2max blocks TKA
Genicularexplicitly non-covered
Coverage Criteria for Peripheral Nerve Blocks
Medically necessary nerve blocks
UHA considers the following nerve blocks medically necessary for the listed indications:
Celiac nerve block — treatment of cancer/malignancy pain.
Cervical plexus block (superficial and deep) — post-operative analgesia after anterior cervical discectomy and fusion; neck surgery (e.g., thyroid); regional anesthesia for carotid endarterectomy.
Combined infraclavicular–suprascapular nerve blocks — post-operative pain control after arthroscopic shoulder surgery.
Fascia iliaca block — acute hip fracture and post-operative pain control following hip (including arthroscopic hip surgery) and knee surgeries.
Femoral nerve block — acute post-operative pain after knee replacement surgery.
Infraclavicular nerve block — regional anesthesia for upper extremity surgery.
Intercostal nerve blocks — acute intercostal pain and chronic intercostal neuritis when used as part of a comprehensive pain management program.
Intercostobrachial nerve block — management of tourniquet pain during surgery.
IPACK (infiltration between popliteal artery and capsule of the knee) block — pain control following ankle arthroplasty, anterior cruciate ligament (ACL) repair, knee arthroscopy, medial meniscectomy, or total knee arthroplasty (TKA).
Lateral femoral cutaneous nerve block — meralgia paresthetica after failure of conservative management (e.g., non-opioid analgesics or anticonvulsants such as carbamazepine, gabapentin, or phenytoin); and pain control after total hip arthroplasty (THA).
Lumbar plexus block — post-operative pain control after THA.
Pectoral plane nerve blocks — post-operative pain control after breast cancer surgery/mastectomy.
Peripheral nerve blocks (continuous or single injection) — treatment of acute pain; chronic pain only when provided as part of an active component of a comprehensive pain management program.
Peripheral nerve blocks — treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g., surgery), and post-operative pain control after arthroscopic debridement of the ankle.
Popliteal block — hallux valgus correction surgery and open reduction internal fixation (ORIF) of ankle fracture.
Posterior tibial nerve block — post-operative pain control after Achilles tendon repair.
Pre-operative adductor canal block — post-operative pain management after anterior cruciate ligament reconstruction.
Quadratus lumborum nerve block — post-operative pain control after abdominal and hip surgeries.
Radial nerve block — post-operative pain control after carpometacarpal joint arthroplasty and De Quervain's tendon release.
Rectus sheath block — post-operative pain control after cholecystectomy.
Saphenous nerve block — post-operative pain management.
Splanchnic nerve block — treatment of cancer/malignancy pain.
Stellate ganglion block — diagnosis of sympathetically mediated pain and treatment of complex regional pain syndrome (CRPS) of the hand and arm when used as part of a rehabilitation program after failure of standard pharmacotherapies (e.g., NSAIDs, topical lidocaine).
Transversus abdominis plane (TAP) block — abdominal surgery.
Ultrasound-guided celiac plexus block — inoperable pancreatic cancer with abdominal pain requiring opioid analgesics, and as a last-resort option for refractory chronic pancreatitis pain despite high-dose opioids.
Ultrasound-guided supraclavicular block — regional anesthesia and post-operative pain control to the distal two-thirds of the upper extremity (mid-humerus to fingertips).
Experimental / investigational / non-covered nerve blocks
UHA considers the following nerve blocks experimental, investigational, or non-covered (not an all-inclusive list) because their effectiveness for these indications has not been established:
Calcaneal nerve block — plantar fasciitis.
Cervical plexus block (superficial and deep) — management of post-operative pain after clavicle ORIF or shoulder surgery, and for treatment of chronic radicular pain/post-laminectomy syndrome.
Cluneal nerve block — including treatment of chronic pelvic pain.
Genicular nerve block — explicitly non-covered per policy.
Combined infraclavicular–suprascapular blocks for shoulder surgery — investigational for this indication.
Erector spinae plane (ESP) block — post-operative pain control after total hip arthroplasty (investigational).
Facial nerve block — treatment of headache/neuralgia.
Ganglion impar block.
Genitofemoral nerve block — chronic pelvic/suprapubic pain.
Greater auricular nerve block — headache.
Greater occipital nerve blocks — diagnosis and treatment of neck and upper back pain.
Ilioinguinal nerve block — chronic pelvic pain syndrome.
Infraclavicular nerve block — treatment of chronic pain (investigational).
Intellicath device — nerve-blocking device for chronic pelvic pain.
Intercostal nerve blocks as sole treatment for chronic intercostal neuritis.
Lateral pectoral nerve block — shoulder pain.
Nerve block for excision of ganglion cyst in the lower extremity.
Nerve block for hemicrania continua.
Nerve hydrodissection — treatment of peripheral nerve entrapment.
Obturator nerve block — treatment of chronic pain.
Occipital nerve block — occipital neuralgia.
Paravertebral block — treatment of chronic pain.
Pectoralis minor nerve block — pectoralis minor syndrome and thoracic outlet syndrome.
Pedicle screw/hardware block of spinal instrumentation.
Pericapsular nerve group (PENG) block — management of post-operative pain (investigational).
Peripheral nerve block as sole treatment for chronic pain.
Peripheral nerve blocks (e.g., greater occipital (GON), supratrochlear (STN), supraorbital (SON)) — treatment of post-herpetic neuralgia and prevention/treatment of headaches including migraine and treatment-refractory migraine in pregnancy, and other headache-related indications.
Popliteal nerve block — post-operative pain after ACL repair (listed investigational).
Posterior femoral cutaneous, pudendal, suboccipital, subscapular, sural, and other named blocks — for various chronic pain indications (investigational).
TAP block — post-operative analgesia following lumbar fusion and after THA (investigational).
Ultrasound-guided ESP block — management of chronic myofascial pain syndrome and post-operative pain (investigational).
Coding and Reimbursement Rules
Unlisted/miscellaneous procedure billingCPT
| unlisted/miscellaneous CPT | When used, must be accompanied by description, operative report, and comparable code |
Maximum reimbursed blocks for TKA
Maximum reimbursed blocks for TKAUHA will reimburse for no more than two approved peripheral nerve blocks to achieve post‑operative pain relief after knee procedures (TKA).
ScopeApplies to post‑operative pain control following total knee arthroplasty (TKA) as noted in limitations/exclusions.
Related requirementBlocks must be performed by skilled and knowledgeable clinicians as stated in policy limitations.
Provider Actions, Documentation, and Authorization
Prior Authorization
No prior authorization required
Prior authorization is not required for peripheral nerve blocks.
Documentation Required
Documentation required for unlisted/miscellaneous codes
When billing with unlisted or miscellaneous CPT codes, include a clear description of the procedure and why standard CPT codes are not appropriate, the operative report, and a reasonably comparable service code/procedure with the request or claim.
- A clear definition or description of the nature, extent and need for the procedure, and why it cannot be addressed with standard coded CPT procedures.
- An operative report.
- A reasonably comparable service code/procedure.
Denial Risk
Retrospective review — keep documentation available
UHA may perform retrospective review and requires legible documentation of medical necessity to be maintained in the patient's medical record and made available on request.
- Documentation supporting medical necessity must be legible and retained in the member's medical record.
- UHA reserves the right to perform retrospective review to validate services and reimbursement and may request the documentation.
Definitions
Peripheral nerve block — definition
DefinitionPeripheral nerve block: injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves or nerve ganglia resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks.
PurposeTo block pain signals and provide prolonged relief for a variety of surgical procedures in inpatient and outpatient settings.
Agents injectedCorticosteroids, local anesthetics, neurolytic agents, and/or sclerosing agents.
Clinical contextUsed for regional anesthesia, perioperative pain management, and may be administered by surgeons for preemptive local anesthesia or periarticular infiltration when appropriate.
Policy Summary
PayerUniversity Health Alliance (HSA)
PolicyPeripheral (Regional) Nerve Block Reimbursement
Policy CodePolicy MPP-0139-220315
Change TypeNo material changes
Effective DateJun 16, 2025
Last ReviewJun 16, 2025
Next Review DateN/A
Key ActionPrior authorization is not required.
SourceLink
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