Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Pain Management of Peripheral Nerves by Injection
Policy #:MA07.047g

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Peripheral nerve injections are considered medically necessary and, therefore, covered for the following indications:
  • Carpal tunnel syndrome and tarsal tunnel syndrome when both of the following criteria are met:
    • If oral agents and orthoses have failed or are contraindicated
    • As adjunctive therapy to systemic agents for an inflammatory arthritis when those agents have not yet become effective and the individual experiences a relative entrapment syndrome manifested by moderate or severe pain
  • Neuromas of the foot (intermetatarsal or interdigital)
    • If the individual has pain or dysfunction resulting from inflammation or other pathological changes

The signs or symptoms that justify peripheral nerve blocks should typically be resolved after one to three injections at a specific site.

NOT MEDICALLY NECESSARY

More than three injections per anatomic site in a six-month period will be considered not medically necessary and, therefore, noncovered.

More than two anatomic sites injected at any one session will be considered not medically necessary and, therefore, noncovered.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, pain management of peripheral nerves by injection is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this policy are met. However, services that are identified as noncovered are not eligible for coverage reimbursement by the Company.

Description

Peripheral nerve blocks involve the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents, and/or neurolytic agents into or near nerves to affect therapy for a pathological condition, such as entrapment, or to provide a local anesthetic block prior to a surgical procedure at a distal site (e.g., digital block for surgical repair).
References

Novitas Solutions. Inc. Local Coverage Determination (LCD): Pain Management of Peripheral Nerves by Injection (L35107). Original Effective Date: 10/01/2015. Revision Effective Date: 10/01/2016. [CMS Website]. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35107&ver=11&Date=10%2f06%2f2015&DocID=L35107&bc=iAAAAAgAIAAAAA%3d%3d&. Accessed January 27, 2017.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODES ARE USED TO REPRESENT INJECTION OF PERIPHERAL NERVES:
20526, 64450, 64455

THE FOLLOWING CODE IS USED TO REPRESENT INJECTION, THERAPEUTIC, TARSAL TUNNEL:
28899


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODES ARE CONSIDERED MEDICALLY NECESSARY WHEN REPORTED WITH 20526:

G56.00 Carpal tunnel syndrome, unspecified upper limb
G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb
G56.03 Carpal tunnel syndrome, bilateral upper limbs

THE FOLLOWING CODES ARE CONSIDERED MEDICALLY NECESSARY WHEN REPORTED WITH 64455:

G57.60 Lesion of plantar nerve, unspecified lower limb
G57.61 Lesion of plantar nerve, right lower limb
G57.62 Lesion of plantar nerve, left lower limb
G57.63 Lesion of plantar nerve, bilateral lower limbs
G57.80 Other specified mononeuropathies of unspecified lower limb
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.83 Other specified mononeuropathies of bilateral lower limb

THE FOLLOWING CODES ARE CONSIDERED MEDICALLY NECESSARY WHEN REPORTED INJECTION, THERAPEUTIC, TARSAL TUNNEL:

G57.50 Tarsal tunnel syndrome, unspecified lower limb
G57.51 Tarsal tunnel syndrome, right lower limb
G57.52 Tarsal tunnel syndrome, left lower limb
G57.53 Tarsal tunnel syndrome, bilateral lower limbs

PLEASE REFER TO ATTACHMENT A FOR A LIST OF ICD-10 CODES THAT ARE CONSIDERED NOT MEDICALLY NECESSARY



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Pain Management of Peripheral Nerves by Injection






Policy History

MA07.047g
01/01/2020This policy has been identified for the annual CPT code update effective 01/01/2020.

The following CPT code narrative has been revised in this policy:

64450

MA07.047f
12/18/2019This policy has been reissued in accordance with the Company's annual review process.
10/01/2019This policy has been identified for an ICD 10 code update, effective 10/01/2019.

The following ICD-10 CM code narratives have been revised in Att A of this policy:

Changed from:
M77.50 Other enthesopathy of unspecified foot

Changed to:
M77.50 Other enthesopathy of unspecified foot and ankle

Changed from:

M77.51 Other enthesopathy of right foot

Changed to:

M77.51 Other enthesopathy of right foot and ankle

Changed from:

M77.52 Other enthesopathy of left foot

Changed to:

M77.52 Other enthesopathy of left foot and ankle



MA07.047e
10/01/2018This policy has been identified for an ICD 10 code update, effective 10/01/2018.

The following ICD-10 CM code has been deleted from Att A of this policy:
M79.1 Myalgia

The following ICD-10 CM codes have been added to Att A of this policy:
M79.10 Myalgia, unspecified site

M79.11 Myalgia of mastication muscle

M79.12 Myalgia of auxiliary muscles, head and neck

M79.18 Myalgia, other site


MA07.047d
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 codes have been added to Attachment A in this policy.
E11.10 Type 2 diabetes mellitus with ketoacidosis without coma
E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

MA.07.047c
05/05/2017The following criteria have been added to this policy:
  • Added Attachment A: ICD-10 Codes considered Not Medically Necessary, with CPT code 64450.

MA.07.047b
12/7/2016This policy was reviewed and reissued to communicate the Company's continuing coverage of pain management of peripheral nerves by injection.
10/01/2016This policy has been identified for an ICD 10 code update, effective 10/01/2016

The following ICD 10 codes were added:
    G56.03 Carpal tunnel syndrome, bilateral upper limbs
    G57.53 Tarsal tunnel syndrome, bilateral lower limbs
    G57.63 Lesion of plantar nerve, bilateral lower limbs
    G57.83 Other specified mononeuropathies of bilateral lower limbs

MA07.047a
06/01/2016This policy has been identified for an ad hoc ICD 10 code update, effective 05/25/2016

The following ICD 10 codes were added:
G57.80, G57.81, G57.82

MA07.047
5/27/2015This policy was reviewed and reissued to communicate the Company's continuing coverage of pain management of peripheral nerves.
01/01/2015This is a new policy.





Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A