Our Member Services Representatives are unavailable Friday, April 10, due to the holiday.

 

CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Pain Management of Peripheral Nerves by Injection

Section: Miscellaneous
Effective Date: July 01, 2018
Revised Date: August 02, 2019

Description

Peripheral nerve blocks involve the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into or near nerves to affect therapy for a pathological condition, such as entrapment, or to provide a local anesthetic block prior to a surgical procedure at a distal site (e.g., digital block for surgical repair).

Criteria

Pain management of peripheral nerves by injection may be considered medically necessary for ANY of the following indications:

  • Carpal tunnel syndrome not relieved by conservative measures including but not limited to pain; paresthesias; and less commonly, weakness in the median nerve distribution; indicated for the individual with carpal tunnel syndrome if oral agents and orthoses have failed or are contraindicated; or as adjunctive therapy to systemic agents for an inflammatory arthritis when those agents have not yet become effective and the individual experiences a relative entrapment syndrome manifested by moderate to severe pain; or
  • Tarsal tunnel syndrome (and no history of trauma), not relieved by conservative measures, including but not limited to non-steroidal anti-inflammatory drugs (NSAIDs), shoe modification, and in some cases orthotics. If the individual does not respond, corticosteroid injection may provide relief and can be useful diagnostically; or
  • Injection into interdigital neuromas (Morton’s, Heuter’s, Hauser’s, and Iselin’s) may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes.Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause; or
  • Injections for plantar fasciitis in individuals in whom initial measures are ineffective within two to three months, a single glucocorticoid injection may be administered. Initial measures include but are not limited to performing of stretching exercises for the plantar fascia and calf muscles, which the individual can do at home; avoiding the use of flat shoes and barefoot walking; using prefabricated, over-the-counter, silicone heel shoe inserts (arch supports and/or heel cups); decreasing physical activities that are suggested by the medical history to be causative or aggravating (e.g., excessive running, dancing, or jumping); prescribing or recommending a short-term trial (two to three weeks) of non-steroidal anti-inflammatory drugs (NSAIDs); injecting the tender areas of the plantar region with glucocorticoids; and a local anesthetic.

When ultrasound guidance is reported, only one (1) unit of service will be reimbursed per date of service per provider.

The signs or symptoms that justify peripheral nerve blocks should be resolved after one (1) to three (3) injections at a specific site.Injections beyond three (3) in a six (6) month period are considered not medically necessary.

Medical necessity for injections of more than two (2) sites at one (1) session or for frequent or repeated injections is considered not medically necessary.

Acupuncture is not to be billed with the procedure codes in this policy. Acupuncture with or without subsequent electrical stimulation is considered not medically necessary.

Procedure Codes

20526 20550 20551 28899 64450 64455 64640
76942 G9770

Alcohol injection into interdigital neuromas (Morton’s, Heuter’s, Hauser’s, and Iselin’s) for the treatment of peripheral nerve pain is considered experimental/investigational; and therefore, not covered. There is a lack of scientific evidence supporting the long-term efficacy of this procedure.

Procedure Codes

64632

Diagnosis Codes

Covered Diagnosis codes for 20526, 28899, 64450

G56.00 G56.01 G56.02 G56.03 G57.10 G57.11 G57.12
G57.50 G57.51 G57.52 G57.53 G57.60 G57.61 G57.62
G57.63 M25.541 M25.542 M25.549

Covered Diagnosis codes for 64455

G57.60 G57.61 G57.62 G57.63 G57.80 G57.81 G57.82
G57.83 M25.541 M25.542 M25.549

Non-covered diagnosis codes for 64450

D48.1 E08.8 E08.9 E08.00 E08.01 E08.10 E08.11
E08.21 E08.22 E08.29 E08.36 E08.39 E08.40 E08.41
E08.42 E08.43 E08.44 E08.49 E08.51 E08.52 E08.59
E08.65 E08.69 E08.311 E08.319 E08.321 E08.329 E08.331
E08.339 E08.341 E08.349 E08.351 E08.359 E08.610 E08.618
E08.620 E08.621 E08.622 E08.628 E08.630 E08.638 E08.641
E08.649 E09.8 E09.9 E09.00 E09.01 E09.10 E09.11
E09.21 E09.22 E09.29 E09.36 E09.39 E09.40 E09.41
E09.42 E09.43 E09.44 E09.49 E09.51 E09.52 E09.59
E09.65 E09.69 E09.311 E09.319 E09.321 E09.329 E09.331
E09.339 E09.341 E09.349 E09.610 E09.618 E09.620 E09.621
E09.622 E09.628 E09.630 E09.638 E09.641 E09.649 E10.8
E10.9 E10.11 E10.21 E10.22 E10.29 E10.36 E10.39
E10.40 E10.41 E10.42 E10.43 E10.44 E10.49 E10.51
E10.52 E10.59 E10.65 E10.69 E10.311 E10.319 E10.321
E10.329 E10.331 E10.339 E10.341 E10.349 E10.351 E10.359
E10.610 E10.618 E10.620 E10.621 E10.622 E10.628 E10.630
E10.638 E10.641 E10.649 E11.8 E11.9 E11.00 E11.01
E11.10 E11.11 E11.21 E11.22 E11.29 E11.36 E11.39
E11.40 E11.41 E11.42 E11.43 E11.44 E11.49 E11.51
E11.52 E11.59 E11.65 E11.69 E11.311 E11.319 E11.321
E11.329 E11.331 E11.339 E11.341 E11.349 E11.351 E11.359
E11.610 E11.618 E11.620 E11.621 E11.622 E11.628 E11.630
E11.638 E11.641 E11.649 E13.8 E13.9 E13.00 E13.01
E13.10 E13.11 E13.21 E13.22 E13.29 E13.40 E13.41
E13.42 E13.43 E13.44 E13.49 E13.51 E13.52 E13.59
E13.65 E13.69 E13.311 E13.319 E13.321 E13.329 E13.331
E13.339 E13.341 E13.349 E13.610 E13.618 E13.620 E13.621
E13.622 E13.628 E13.630 E13.638 E13.641 E13.649 E78.1
M07.671 M07.672 M07.679 M10.9 M12.9 M12.871 M12.872
M12.879 M16.9 M17.9 M19.90 M19.019 M24.20 M24.211
M24.212 M24.219 M24.221 M24.222 M24.229 M24.231 M24.232
M24.239 M24.241 M24.242 M24.249 M24.251 M24.252 M24.259
M24.271 M24.272 M24.273 M24.274 M24.275 M24.276 M25.9
M25.70 M25.151 M25.152 M25.159 M25.171 M25.172 M25.173
M25.174 M25.175 M25.176 M25.511 M25.512 M25.519 M25.551
M25.552 M25.559 M25.561 M25.562 M25.569 M25.571 M25.572
M25.579 M25.671 M25.672 M25.673 M25.674 M25.675 M25.676
M25.711 M25.712 M25.719 M25.751 M25.752 M25.759 M25.771
M25.772 M25.773 M25.774 M25.775 M25.776 M25.851 M25.852
M25.859 M25.871 M25.872 M25.879 M46.1 M60.80 M60.811
M60.812 M60.819 M60.821 M60.822 M60.829 M60.831 M60.832
M60.839 M60.841 M60.842 M60.849 M60.851 M60.852 M60.859
M60.861 M60.862 M60.869 M60.871 M60.872 M60.879 M60.9
M62.40 M62.411 M62.412 M62.419 M62.421 M62.422 M62.429
M62.431 M62.432 M62.439 M62.441 M62.442 M62.449 M62.451
M62.452 M62.459 M62.461 M62.462 M62.469 M62.471 M62.472
M62.479 M62.48 M62.49 M62.831 M62.838 M65.4 M65.9
M65.10 M65.20 M65.28 M65.30 M65.80 M65.111 M65.112
M65.119 M65.121 M65.122 M65.129 M65.131 M65.132 M65.139
M65.141 M65.142 M65.149 M65.151 M65.152 M65.159 M65.161
M65.162 M65.169 M65.171 M65.221 M65.222 M65.229 M65.231
M65.232 M65.239 M65.241 M65.242 M65.249 M65.251 M65.252
M65.259 M65.261 M65.262 M65.269 M65.271 M65.272 M65.279
M65.311 M65.312 M65.319 M65.321 M65.322 M65.329 M65.331
M65.332 M65.339 M65.341 M65.342 M65.349 M65.351 M65.352
M65.359 M65.831 M65.832 M65.839 M65.841 M65.842 M65.849
M65.871 M65.872 M65.879 M67.90 M67.911 M67.912 M67.919
M67.921 M67.922 M67.929 M67.931 M67.932 M67.939 M67.941
M67.942 M67.949 M67.951 M67.952 M67.959 M67.961 M67.962
M67.969 M67.971 M70.60 M70.61 M70.62 M70.70 M70.71
M70.72 M70.90 M70.911 M70.912 M70.919 M70.921 M70.922
M70.929 M70.931 M70.932 M70.939 M70.941 M70.942 M70.949
M70.951 M70.952 M70.959 M70.961 M70.962 M70.969 M70.971
M72.2 M75.30 M75.31 M75.32 M75.40 M75.41 M75.42
M75.80 M75.81 M75.82 M75.90 M75.91 M75.92 M76.00
M76.01 M76.02 M76.10 M76.11 M76.12 M76.20 M76.21
M76.22 M76.30 M76.31 M76.60 M76.61 M76.62 M76.70
M76.71 M76.72 M76.811 M76.812 M76.819 M76.821 M76.822
M76.829 M76.899 M77.30 M77.31 M77.32 M77.40 M77.41
M77.42 M77.50 M77.51 M77.52 M77.9 M79.10 M79.11
M79.12 M79.18 M79.7 M79.9 M79.A9 Q68.6 Q79.8
Q79.9 S43.421A S43.421D S43.421S S43.422A S43.422D S43.422S
S43.429A S43.429D S43.429S

Links