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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that 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 patients 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 may be covered for epidural injections. It is inappropriate to bill for 
fluoroscopy (CPT

 codes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of 
service for the same patient by the same provider are included in the CPT

 description of the procedure(s) 
performed. 
 
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. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35457: Nerve Blockade for 
Treatment of Chronic Pain and Neuropathy. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.