**Abstract:**  
  
Peripheral nerves can be the cause of pain in a variety of conditions.
Sometimes the nerves are the source of the pain and sometimes the nerves
merely are carrying impulses from painful tissues. Examples may include: post-
herniorrhaphy pain (ilioinguinal/iliohypogastric/genitofemoral), iliac crest
harvest syndromes (cluneal nerve, lateral femoral cutaneous nerve), carpal
tunnel syndrome (median nerve), Morton's neuroma, facial pain and headaches
(trigeminal and occipital nerve).  
  
Peripheral nerve blocks may be used for both diagnostic and therapeutic
purposes. Diagnostically, a peripheral nerve block allows the clinician to
isolate the specific cause of pain in an individual patient. The injection of
local anesthetic, with or without steroid may also provide an extended
therapeutic benefit. If the patient does not achieve sustained relief a
denervation procedure via chemical, cryoneurolysis or radiofrequency may not
be effective at providing long term relief.  
  
 **Indications:**  
  
Peripheral nerve blocks will be considered medically reasonable and necessary
for normally temporary conditions such as the following diagnostic and
therapeutic purposes:  
  

  1. When the patient's 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.   
  

  2. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome.   
  

  3. 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.   
  

  4. 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.  
  

  5. 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.  
  

  6. 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).  
  

  7. 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)  
  
 **Limitations:**  
  
The signs and symptoms that justify peripheral nerve blocks should be resolved
after one to three injections at a specific site. They cannot be for clinical
situations as mentioned below where nerve blocks are not medically necessary
as per this LCD. More than three injections per anatomic site (e.g., specific
nerve, plexus or branch as defined by the CPT code description) in a six month
period will be denied. These blocks should last at least two months in order
to be deemed successful. In rare exceptions with appropriate documentation,
there is a limit of three blocks per six month period.

More than two anatomic sites (e.g., specific nerve, plexus or branch as
defined by the CPT code description) injected at any one session will be
denied. If the patient does not achieve progressively sustained relief after
receiving two to three repeat peripheral nerve block injections on the same
anatomical site, then alternative therapeutic options should be explored.

There is insufficient evidence to support the use of peripheral nerve blocks
in the treatment of diabetic peripheral neuropathy, peripheral neuropathies
caused by other underlying systemic diseases or peripheral neuropathies causes
such as degenerative or idiopathic reasons. Medical management using systemic
medications is clinically indicated for the treatment of these conditions.  
  
At present, the literature and scientific evidence supporting the use of
peripheral nerve blocks with or without the use of electrostimulation, and the
use of electrostimulation alone for neuropathies or peripheral neuropathies
caused by underlying systemic diseases is insufficient to warrant coverage.
These procedures are considered investigational and are not eligible for
coverage for the treatment of neuropathies or peripheral neuropathies caused
by underlying systemic diseases.

The use of ultrasound guidance in conjunction with these non-covered
injections is also considered not medically necessary and will result in
denial.  
  
Note: the term "Morton's neuroma" is used in this document generically to
refer to a swollen inflamed nerve in the ball of the foot, including the more
specific conditions of Morton's neuroma (lesion within the third
intermetatarsal space), Heuter's neuroma (first intermetatarsal space),
Hauser's neuroma (second intermetatarsal space) and Iselin's neuroma (fourth
intermetatarsal space). This LCD applies to each such condition.  
  
Injection into neuromas 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.  
  
Medical necessity for injections of more than two sites at one session or for
frequent or repeated injections is questionable and not supported by peer
literature that is indexed in PubMed of the US National Library of Medicine of
the National Institutes of Health (NIH).  
  
"Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves,
tendon sheaths and their origins/insertions, or any tissue are non-covered
procedures.