Coverage Indications, Limitations, and/or Medical Necessity
For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for three months or more.
Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been established.
• Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered.
• Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may be maintained through the infusion of local anesthetics via indwelling catheter.
Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation.
Imaging guidance with fluoroscopy, CT or ultrasound may be necessary to perform somatic nerve blockade. Only fluoroscopic or CT guidance will be covered for epidural injections.
Provider Qualifications
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
Patient safety and quality of care mandate that healthcare professionals who perform Nerve Blocks are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities.
PERIPHERAL NEUROPATHY
• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.
• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.
• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.
SOMATIC NERVE BLOCK
• Radiculopathy and other neurological deficits require further evaluation and management prior to performing the blocks.
EPIDURAL BLOCK (Cervical and Thoracic)
This policy does not cover lumbar epidural blocks, which are covered in another Noridian policy.
• Injections should not be repeated in less than five days.
• Injections are limited to a total of three in a three to six month period of time and should only be repeated if the injections produced significant and sustained relief documented by objective evidence, including improvements in the ability to perform activities of daily living (ADLs).
• Steroids should be used only in the presence of radiculopathy. Particulate steroids in the cervical region have been shown to be hazardous.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph: CPT codes 64450 or 64640 may not be billed with diagnosis G57.61 and G57.62. The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma.
Group 1 Codes:
62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC
62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62321 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62325 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
64402 INJECTION, ANESTHETIC AGENT; FACIAL NERVE
64405 INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE
64408 INJECTION, ANESTHETIC AGENT; VAGUS NERVE
64410 INJECTION, ANESTHETIC AGENT; PHRENIC NERVE
64413 INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS
64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE
64417 INJECTION, ANESTHETIC AGENT; AXILLARY NERVE
64418 INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE
64420 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE
64421 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, REGIONAL BLOCK
64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES
64430 INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE
64435 INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE
64445 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE
64446 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE
64448 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64449 INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64455 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)
64461 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64462 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SECOND AND ANY ADDITIONAL INJECTION SITE(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64463 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; CONTINUOUS INFUSION BY CATHETER (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64479 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL
64480 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64505 INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION
64508 INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE PROCEDURE)
64510 INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)
64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS
64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)
64530 INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING
64620 DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE
64632 DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE
64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
Group 2 Paragraph: CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes listed PLUS any one of the GROUP 1 diagnosis listed in the ICD-10 Codes the DO NOT Support Medical Necessity section below.
Group 2 Codes:
64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
76881 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE
76882 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION
76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)
97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES
97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)
G0282 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281
G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
B02.0 Zoster encephalitis
B02.1 Zoster meningitis
B02.21 Postherpetic geniculate ganglionitis
B02.22 Postherpetic trigeminal neuralgia
B02.23 Postherpetic polyneuropathy
B02.24 Postherpetic myelitis
B02.29 Other postherpetic nervous system involvement
B02.7 Disseminated zoster
B02.8 Zoster with other complications
B02.9 Zoster without complications
G50.0 Trigeminal neuralgia
G54.0 Brachial plexus disorders
G54.1 Lumbosacral plexus disorders
G54.2 Cervical root disorders, not elsewhere classified
G54.3 Thoracic root disorders, not elsewhere classified
G54.4 Lumbosacral root disorders, not elsewhere classified
G54.5 Neuralgic amyotrophy
G54.6 Phantom limb syndrome with pain
G54.8 Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limbs
G56.11 Other lesions of median nerve, right upper limb
G56.12 Other lesions of median nerve, left upper limb
G56.13 Other lesions of median nerve, bilateral upper limbs
G56.21 Lesion of ulnar nerve, right upper limb
G56.22 Lesion of ulnar nerve, left upper limb
G56.23 Lesion of ulnar nerve, bilateral upper limbs
G56.31 Lesion of radial nerve, right upper limb
G56.32 Lesion of radial nerve, left upper limb
G56.33 Lesion of radial nerve, bilateral upper limbs
G56.41 Causalgia of right upper limb
G56.42 Causalgia of left upper limb
G56.43 Causalgia of bilateral upper limbs
G56.81 Other specified mononeuropathies of right upper limb
G56.82 Other specified mononeuropathies of left upper limb
G56.91 Unspecified mononeuropathy of right upper limb
G56.92 Unspecified mononeuropathy of left upper limb
G57.01 Lesion of sciatic nerve, right lower limb
G57.02 Lesion of sciatic nerve, left lower limb
G57.03 Lesion of sciatic nerve, bilateral lower limbs
G57.11 Meralgia paresthetica, right lower limb
G57.12 Meralgia paresthetica, left lower limb
G57.13 Meralgia paresthetica, bilateral lower limbs
G57.21 Lesion of femoral nerve, right lower limb
G57.22 Lesion of femoral nerve, left lower limb
G57.23 Lesion of femoral nerve, bilateral lower limbs
G57.31 Lesion of lateral popliteal nerve, right lower limb
G57.32 Lesion of lateral popliteal nerve, left lower limb
G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs
G57.41 Lesion of medial popliteal nerve, right lower limb
G57.42 Lesion of medial popliteal nerve, left lower limb
G57.43 Lesion of medial popliteal nerve, bilateral lower limbs
G57.51 Tarsal tunnel syndrome, right lower limb
G57.52 Tarsal tunnel syndrome, left lower limb
G57.53 Tarsal tunnel syndrome, bilateral lower limbs
G57.61* Lesion of plantar nerve, right lower limb
G57.62* Lesion of plantar nerve, left lower limb
G57.63* Lesion of plantar nerve, bilateral lower limbs
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.91* Unspecified mononeuropathy of right lower limb
G57.92* Unspecified mononeuropathy of left lower limb
G58.0 Intercostal neuropathy
G58.7* Mononeuritis multiplex
G58.8* Other specified mononeuropathies
G58.9* Mononeuropathy, unspecified
G59* Mononeuropathy in diseases classified elsewhere
G89.11 Acute pain due to trauma
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
G89.21 Chronic pain due to trauma
G89.22 Chronic post-thoracotomy pain
G89.28 Other chronic postprocedural pain
G89.3 Neoplasm related pain (acute) (chronic)
G90.50 Complex regional pain syndrome I, unspecified
G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb
G90.513 Complex regional pain syndrome I of upper limb, bilateral
G90.521 Complex regional pain syndrome I of right lower limb
G90.522 Complex regional pain syndrome I of left lower limb
G90.523 Complex regional pain syndrome I of lower limb, bilateral
G90.59 Complex regional pain syndrome I of other specified site
I73.00 Raynaud's syndrome without gangrene
I73.01 Raynaud's syndrome with gangrene
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M43.27 Fusion of spine, lumbosacral region
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *R07.9 is used to describe rib pain
*G57.61, G57.62, G57.63 - The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma. CPT codes 64450 or 64640 may not be billed with diagnosis G57.61, G57.62 or G57.63.
*G57.91, G57.92, G58.7, G58.8, G58.9, G59, M54.10 and M79.2 - Is allowed when 64450 is billed WITHOUT CPT codes 76881, 76882, 76942, 76999, 97032, 97139, G0282 and/or G0283 on the same date of service (DOS). (Please see information in the ICD-10 Codes that DO NOT Support Medical Necessity section below).
G57.91 Unspecified mononeuropathy of right lower limb
G57.92 Unspecified mononeuropathy of left lower limb
G58.7 Mononeuritis multiplex
G58.8 Other specified mononeuropathies
G58.9 Mononeuropathy, unspecified
G60.0 Hereditary motor and sensory neuropathy
G60.1 Refsum's disease
G60.2 Neuropathy in association with hereditary ataxia
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified
G61.0 Guillain-Barre syndrome
G61.1 Serum neuropathy
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.89 Other inflammatory polyneuropathies
G61.9 Inflammatory polyneuropathy, unspecified
G62.0 Drug-induced polyneuropathy
G62.2 Polyneuropathy due to other toxic agents
G62.81 Critical illness polyneuropathy
G62.82 Radiation-induced polyneuropathy
G62.89 Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M54.10 Radiculopathy, site unspecified
M79.2 Neuralgia and neuritis, unspecified
R20.0 Anesthesia of skin
R20.1 Hypoesthesia of skin
R20.2 Paresthesia of skin
R20.3 Hyperesthesia
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbances of skin sensation
For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for three months or more.
Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. Their utility in the diagnosis and treatment of non-neuropathic pain and specific syndromes mediated by sympathetic nervous system overactivity has been established.
• Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the brain and spinal cord) or peripheral (outside the brain and spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered.
• Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. When blockade has been of value in the relief of acute or chronic cancer related pain, somatic or epidural blockade may be maintained through the infusion of local anesthetics via indwelling catheter.
Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation.
Imaging guidance with fluoroscopy, CT or ultrasound may be necessary to perform somatic nerve blockade. Only fluoroscopic or CT guidance will be covered for epidural injections.
Provider Qualifications
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
Patient safety and quality of care mandate that healthcare professionals who perform Nerve Blocks are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities.
PERIPHERAL NEUROPATHY
• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.
• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.
• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.
SOMATIC NERVE BLOCK
• Radiculopathy and other neurological deficits require further evaluation and management prior to performing the blocks.
EPIDURAL BLOCK (Cervical and Thoracic)
This policy does not cover lumbar epidural blocks, which are covered in another Noridian policy.
• Injections should not be repeated in less than five days.
• Injections are limited to a total of three in a three to six month period of time and should only be repeated if the injections produced significant and sustained relief documented by objective evidence, including improvements in the ability to perform activities of daily living (ADLs).
• Steroids should be used only in the presence of radiculopathy. Particulate steroids in the cervical region have been shown to be hazardous.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph: CPT codes 64450 or 64640 may not be billed with diagnosis G57.61 and G57.62. The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma.
Group 1 Codes:
62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC
62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62321 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62324 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62325 INJECTION(S), INCLUDING INDWELLING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
64402 INJECTION, ANESTHETIC AGENT; FACIAL NERVE
64405 INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE
64408 INJECTION, ANESTHETIC AGENT; VAGUS NERVE
64410 INJECTION, ANESTHETIC AGENT; PHRENIC NERVE
64413 INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS
64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE
64417 INJECTION, ANESTHETIC AGENT; AXILLARY NERVE
64418 INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE
64420 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE
64421 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, REGIONAL BLOCK
64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES
64430 INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE
64435 INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE
64445 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE
64446 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE
64448 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64449 INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT)
64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
64455 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)
64461 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SINGLE INJECTION SITE (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64462 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; SECOND AND ANY ADDITIONAL INJECTION SITE(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64463 PARAVERTEBRAL BLOCK (PVB) (PARASPINOUS BLOCK), THORACIC; CONTINUOUS INFUSION BY CATHETER (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)
64479 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL
64480 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64505 INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION
64508 INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE PROCEDURE)
64510 INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)
64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS
64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)
64530 INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC MONITORING
64620 DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE
64632 DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR COMMON DIGITAL NERVE
64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
Group 2 Paragraph: CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes listed PLUS any one of the GROUP 1 diagnosis listed in the ICD-10 Codes the DO NOT Support Medical Necessity section below.
Group 2 Codes:
64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH
76881 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE
76882 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC
76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION
76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)
97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES
97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)
G0282 ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN DESCRIBED IN G0281
G0283 ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
B02.0 Zoster encephalitis
B02.1 Zoster meningitis
B02.21 Postherpetic geniculate ganglionitis
B02.22 Postherpetic trigeminal neuralgia
B02.23 Postherpetic polyneuropathy
B02.24 Postherpetic myelitis
B02.29 Other postherpetic nervous system involvement
B02.7 Disseminated zoster
B02.8 Zoster with other complications
B02.9 Zoster without complications
G50.0 Trigeminal neuralgia
G54.0 Brachial plexus disorders
G54.1 Lumbosacral plexus disorders
G54.2 Cervical root disorders, not elsewhere classified
G54.3 Thoracic root disorders, not elsewhere classified
G54.4 Lumbosacral root disorders, not elsewhere classified
G54.5 Neuralgic amyotrophy
G54.6 Phantom limb syndrome with pain
G54.8 Other nerve root and plexus disorders
G55 Nerve root and plexus compressions in diseases classified elsewhere
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limbs
G56.11 Other lesions of median nerve, right upper limb
G56.12 Other lesions of median nerve, left upper limb
G56.13 Other lesions of median nerve, bilateral upper limbs
G56.21 Lesion of ulnar nerve, right upper limb
G56.22 Lesion of ulnar nerve, left upper limb
G56.23 Lesion of ulnar nerve, bilateral upper limbs
G56.31 Lesion of radial nerve, right upper limb
G56.32 Lesion of radial nerve, left upper limb
G56.33 Lesion of radial nerve, bilateral upper limbs
G56.41 Causalgia of right upper limb
G56.42 Causalgia of left upper limb
G56.43 Causalgia of bilateral upper limbs
G56.81 Other specified mononeuropathies of right upper limb
G56.82 Other specified mononeuropathies of left upper limb
G56.91 Unspecified mononeuropathy of right upper limb
G56.92 Unspecified mononeuropathy of left upper limb
G57.01 Lesion of sciatic nerve, right lower limb
G57.02 Lesion of sciatic nerve, left lower limb
G57.03 Lesion of sciatic nerve, bilateral lower limbs
G57.11 Meralgia paresthetica, right lower limb
G57.12 Meralgia paresthetica, left lower limb
G57.13 Meralgia paresthetica, bilateral lower limbs
G57.21 Lesion of femoral nerve, right lower limb
G57.22 Lesion of femoral nerve, left lower limb
G57.23 Lesion of femoral nerve, bilateral lower limbs
G57.31 Lesion of lateral popliteal nerve, right lower limb
G57.32 Lesion of lateral popliteal nerve, left lower limb
G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs
G57.41 Lesion of medial popliteal nerve, right lower limb
G57.42 Lesion of medial popliteal nerve, left lower limb
G57.43 Lesion of medial popliteal nerve, bilateral lower limbs
G57.51 Tarsal tunnel syndrome, right lower limb
G57.52 Tarsal tunnel syndrome, left lower limb
G57.53 Tarsal tunnel syndrome, bilateral lower limbs
G57.61* Lesion of plantar nerve, right lower limb
G57.62* Lesion of plantar nerve, left lower limb
G57.63* Lesion of plantar nerve, bilateral lower limbs
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.73 Causalgia of bilateral lower limbs
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.91* Unspecified mononeuropathy of right lower limb
G57.92* Unspecified mononeuropathy of left lower limb
G58.0 Intercostal neuropathy
G58.7* Mononeuritis multiplex
G58.8* Other specified mononeuropathies
G58.9* Mononeuropathy, unspecified
G59* Mononeuropathy in diseases classified elsewhere
G89.11 Acute pain due to trauma
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
G89.21 Chronic pain due to trauma
G89.22 Chronic post-thoracotomy pain
G89.28 Other chronic postprocedural pain
G89.3 Neoplasm related pain (acute) (chronic)
G90.50 Complex regional pain syndrome I, unspecified
G90.511 Complex regional pain syndrome I of right upper limb
G90.512 Complex regional pain syndrome I of left upper limb
G90.513 Complex regional pain syndrome I of upper limb, bilateral
G90.521 Complex regional pain syndrome I of right lower limb
G90.522 Complex regional pain syndrome I of left lower limb
G90.523 Complex regional pain syndrome I of lower limb, bilateral
G90.59 Complex regional pain syndrome I of other specified site
I73.00 Raynaud's syndrome without gangrene
I73.01 Raynaud's syndrome with gangrene
L74.510 Primary focal hyperhidrosis, axilla
L74.511 Primary focal hyperhidrosis, face
L74.512 Primary focal hyperhidrosis, palms
L74.513 Primary focal hyperhidrosis, soles
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M43.27 Fusion of spine, lumbosacral region
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *R07.9 is used to describe rib pain
*G57.61, G57.62, G57.63 - The correct CPT procedure codes are 64455 or 64632 when billing for the diagnosis of Morton’s Neuroma. CPT codes 64450 or 64640 may not be billed with diagnosis G57.61, G57.62 or G57.63.
*G57.91, G57.92, G58.7, G58.8, G58.9, G59, M54.10 and M79.2 - Is allowed when 64450 is billed WITHOUT CPT codes 76881, 76882, 76942, 76999, 97032, 97139, G0282 and/or G0283 on the same date of service (DOS). (Please see information in the ICD-10 Codes that DO NOT Support Medical Necessity section below).
G57.91 Unspecified mononeuropathy of right lower limb
G57.92 Unspecified mononeuropathy of left lower limb
G58.7 Mononeuritis multiplex
G58.8 Other specified mononeuropathies
G58.9 Mononeuropathy, unspecified
G60.0 Hereditary motor and sensory neuropathy
G60.1 Refsum's disease
G60.2 Neuropathy in association with hereditary ataxia
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified
G61.0 Guillain-Barre syndrome
G61.1 Serum neuropathy
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.89 Other inflammatory polyneuropathies
G61.9 Inflammatory polyneuropathy, unspecified
G62.0 Drug-induced polyneuropathy
G62.2 Polyneuropathy due to other toxic agents
G62.81 Critical illness polyneuropathy
G62.82 Radiation-induced polyneuropathy
G62.89 Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M54.10 Radiculopathy, site unspecified
M79.2 Neuralgia and neuritis, unspecified
R20.0 Anesthesia of skin
R20.1 Hypoesthesia of skin
R20.2 Paresthesia of skin
R20.3 Hyperesthesia
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbances of skin sensation
