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

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

Diagnosis Codes

Covered Diagnosis codes for 20526, 28899, 64450

Covered Diagnosis codes for 64455

Non-covered diagnosis codes for 64450