Appeal type: unknown
Decision: unknown

 
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 peripheral nerve blocks will be considered medically reasonable and necessary for normally 
temporary conditions such as the following diagnostic and therapeutic purposes: 
 
    When the patients pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have 
failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation 
but this is only for diagnostic purposes and not long term treatment. 
 
    When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain 
syndrome. 
 
    When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is 
unclear but this is only for diagnostic purposes and not long term treatment. 
 
    When an occipital nerve block is used to confirm the clinical impression of the presence of occipital 
neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as the result 
of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or bilateral, constant 
or intermittent. Nerve injury secondary to localized head trauma or trauma to the nerve from a scalp laceration 
can also cause this condition. Most commonly it is caused by an entrapment of the occipital nerve in its course 
from its origin from the C2 nerve root to its entrance into the scalp through the mid portion of the superior 
nuchal line. Blockage of the occipital nerve can confirm the clinical impression of occipital neuralgia 
particularly if the clinical picture is not entirely typical. If only temporary relief of symptoms is obtained, 
neurolysis of the greater occipital nerve may be considered via multiple techniques including radiofrequency 
and cryoanalgesia. In addition, the lesser and third occipital nerves can be involved in the pathology of 
headaches and can be treated in a similar manner. 
 
    When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve. 
Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a syndrome of 
pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When the history and 
examination point to the diagnosis, a suprascapular nerve block leading to relief of pain can confirm it. This may be followed by injection of depository steroids that sometime provide lasting relief. 
 
    When the trigeminal nerve is blocked centrally at the trigeminal ganglion, or along one of the three divisions 
or at one of the many peripheral terminal branches (i.e., supraorbital nerve). 
 
    Nerve blocks as preemptive analgesia 
 
 A. When a single injection peripheral nerve block provides post-surgical pain control 
 
1. during the transition to oral analgesics 
 
2. in those procedures which cause severe pain normally uncontrolled by oral analgesics 
 
3. in cases otherwise requiring control with intravenous or parenteral narcotics. 
 
4. in cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects, etc. 
 
 B. When a continuous peripheral nerve block provides the same as above, and furthermore may provide 
extended (i.e. one to five or more days) relief as a result of chronic administration of anesthetic. 
 
Additional management using medications, behavioral therapy, and physical therapy should be used (when 
appropriate) in conjunction with peripheral nerve block. 
 
Injection of depository steroids, may offer only temporary relief. In some cases, neurolysis may be appropriate 
to provide lasting relief. 
 
Preemptive analgesia starts before surgery, and a presumption of medical necessity is being made before the 
fact. Therefore, based on generally accepted clinical standards and evidence in peer reviewed medical literature 
the surgical procedure must be of such nature that the patient would benefit from the preemptive analgesia. 
However, its billing must conform to National Correct Coding Initiative edit policy. (NCCI Policy Manual for 
Medicare Services Chapter II Anesthesia Services) 
 
You can find this information in the Local Coverage Determination (LCD) Peripheral Nerve Blocks L36850. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.