Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for ultrasonic guidance for needle placement (code 76942) and unlisted 
procedure nervous system (code 64999). We decided that the Plan does not have to pay for peripheral nerve 
block for osteoarthritis (code 64448). 
 
You asked the Plan to pay for peripheral nerve block for osteoarthritis (code 64448), ultrasonic guidance for 
needle placement (code 76942) and unlisted procedure nervous system (code 64999) for unilateral primary 
osteoarthritis, left knee (diagnosis code M1712) provided on October 24, 2022. You say that peripheral nerve 
block for osteoarthritis (code 64448), ultrasonic guidance for needle placement (code 76942) and unlisted 
procedure nervous system (code 64999) for unilateral primary osteoarthritis were medically necessary. The 
Plan says that peripheral nerve block for osteoarthritis (code 64448), ultrasonic guidance for needle placement 
(code 76942) and unlisted procedure nervous system (code 64999) for unilateral primary osteoarthritis, were 
not medically necessary. 
 
We decided that the Plan has to pay for ultrasonic guidance for needle placement (code 76942) and 
unlisted procedure nervous system (code 64999) provided on October 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for peripheral nerve block for osteoarthritis, 
ultrasonic guidance for needle placement and unlisted procedure nervous system for unilateral primary 
osteoarthritis, left knee. Our reviewer says that the requested ultrasonic guidance for needle placement and 
unlisted procedure nervous system are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of primary osteoarthritis of the left knee underwent a left 
total knee replacement (TKR) on October 24, 2022. The enrollee received general anesthesia (with LMA) 
during the surgery and an adductor canal block for post-operative analgesia and an IPACK block (Infiltration 
between Popliteal Artery and Capsule of the Knee). The block was done (prior to the surgery) at the "surgeon's 
request" for post-operative pain management. Anesthesia time:  07:11 - 08:34. Prior to the induction of general 
anesthesia, a left adductor canal block was done Ropivacaine 0.5%, 20ml injection) by the anesthesiologist 
under IV sedation and ultrasound guidance and left Infiltration between Popliteal Artery and Capsule of the 
Knee (IPACK) (Ropivacaine 0.2% injection 20ml injection. The enrollee tolerated the procedure well. Nerve 
blocks are a necessary part of many surgical procedures for a total loss of feeling if needed for surgery and are 
often also used for post-operative pain relief, but if the block is not documented as being for post-operative 
pain management, then it is assumed to only be used for the surgery and therefore included in the surgical 
package and not coded separately. If the anesthesiologist provided the nerve block, code the American Society 
of Anesthesiologists (ASA) Anesthesia Current Procedural Terminology (CPT) code, unless the block is for 
post-operative pain management in which case both the nerve block and the ASA anesthesia CPT can be 
coded. In this case, the regional blocks were for post-operative pain management and can be coded separately. 
The IPACK block (done for ICD-10 G89.18 Other acute post-procedural pain) should be coded with  
CPT 64499. Ultrasonic guidance for needle placement CPT 76942 appears to be coded correctly for 2022.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for needle placement (code 76942) and unlisted procedure 
nervous system (code 64999) have been met. Therefore, we decided that the Plan has to pay for ultrasonic 
guidance for needle placement (code 76942) and unlisted procedure nervous system (code 64999) provided on 
October 24, 2022.   
 
 
We also decided that the Plan does not have to pay for peripheral nerve block for osteoarthritis 
(code 64448) provided on October 24, 2022. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for peripheral nerve block for osteoarthritis, 
ultrasonic guidance for needle placement and unlisted procedure nervous system for unilateral primary 
osteoarthritis, left knee. Our reviewer says that the requested ultrasonic guidance for needle placement and 
unlisted procedure nervous system are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of primary osteoarthritis of the left knee underwent a left 
total knee replacement (TKR) on October 24, 2022. The enrollee received general anesthesia (with LMA) 
during the surgery and an adductor canal block for post-operative analgesia and an IPACK block (Infiltration 
between Popliteal Artery and Capsule of the Knee). The block was done (prior to the surgery) at the "surgeon's 
request" for post-operative pain management. Anesthesia time:  07:11 - 08:34. Prior to the induction of general 
anesthesia, a left adductor canal block was done Ropivacaine 0.5%, 20ml injection) by the anesthesiologist 
under IV sedation and ultrasound guidance and left Infiltration between Popliteal Artery and Capsule of the 
Knee (IPACK) (Ropivacaine 0.2% injection 20ml injection. The enrollee tolerated the procedure well. Nerve 
blocks are a necessary part of many surgical procedures for a total loss of feeling if needed for surgery and are 
often also used for post-operative pain relief, but if the block is not documented as being for post-operative 
pain management, then it is assumed to only be used for the surgery and therefore included in the surgical 
package and not coded separately. If the anesthesiologist provided the nerve block, code the American Society 
of Anesthesiologists (ASA) Anesthesia Current Procedural Terminology (CPT) code, unless the block is for 
post-operative pain management in which case both the nerve block and the ASA anesthesia CPT can be 
coded. In this case, the regional blocks were for post-operative pain management and can be coded separately.  
Anatomically, the common approaches for "adductor canal" blocks describe insertion sites that are located 
within the femoral triangle and target major branches of the femoral nerve. This justifies 64447 for single-
injection and 64448 for continuous blocks. In this case, the adductor canal block appeared to be a single-
injection and should be coded with CPT 64447-59-LT (not 64448-59-LT). The regional nerve block 
should be reimbursed for postoperative pain management. However, the billed code (CPT 64448) is 
incorrect. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve block for osteoarthritis (code 64448) for unilateral primary 
osteoarthritis, left knee have not been met. Therefore, we decided that the Plan does not have to pay for 
peripheral nerve block for osteoarthritis (code 64448) for unilateral primary osteoarthritis, left knee provided 
on October 24, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.