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 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.  
  
 **_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 epidural blocks, which are covered in another
Noridian policy. Please refer to L39242/A58995.

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