Commercial

Medical Policy

Notification

Pain Management of Peripheral Nerves by Injection

Notification Issue Date:

This version of the policy will become effective 12/27/2021.

The following new policy has been developed to communicate the Company’s coverage criteria for Pain Management of Peripheral Nerves by Injection.

Title:

Pain Management of Peripheral Nerves by Injection

Policy #:

07.03.27

Policy

MEDICALLY NECESSARY

Peripheral nerve injections are considered medically necessary and, therefore, covered for the following indications:

Carpal tunnel syndrome when ANY of the following criteria are met:

Oral agents and orthoses have failed or are contraindicated; or

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.

Tarsal tunnel syndrome when ANY of the following criteria are met:

Oral agents and orthoses have failed or are contraindicated; or
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.

Intermetatarsal or interdigital neuromas of the foot (e.g., Morton’s Neuroma, Heuter's Neuroma, Hauser's Neuroma, Iselin's Neuroma)
- Short-term injections of local anesthetics and/or steroids to relieve 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

Peripheral nerve injections for any other indication are considered not medically necessary and, therefore, noncovered.

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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, pain management of peripheral nerves by injection is covered under the medical benefits of the Company's 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 for pain management involve the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents, and/or neurolytic agents into or near the peripheral nerves to affect therapy for a pathological condition, such as nerve entrapment, or to provide a local anesthetic block prior to a surgical procedure at a distal site (e.g., digital block for surgical repair).

Injection therapies for tarsal tunnel syndrome and Morton’s neuroma do not involve a direct injection into the peripheral nerves but refer to focal injections of tissue surrounding a specific focus of inflammation on the foot.

The term "Morton's neuroma" is used 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).

References

Bansal P. Dexmedetomidine as an adjuvant to local anaesthetic agents in peripheral nerve blocks: A Review. J Clin Diagn Res. 2019;13(1).

Barrett SL, Nickerson DS, Elison P, et al. Clinical practice Guidelines 2020. Association of Extremity Nerve Surgeons; 2020.

Chen PC, Chuang CH, Tu YK, et al. A Bayesian network meta-analysis: Comparing the clinical effectiveness of local corticosteroid injections using different treatment strategies for carpal tunnel syndrome. BMC Musculoskelet Disord. 2015;16:363.

Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' committeeon regional anesthesia, executive committee, and administrative council. J Pain. 2016;17(2), pp.131-157.

Evers S, Bryan AJ, Sanders TL, et al. Corticosteroid injections for carpal tunnel syndrome: long- term follow-up in a population-based cohort. Plast Reconstr Surg. 2017;140(2):338.

Johannsen FE, Herzog RB, Malmgaard-Clausen NM, et al. Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):5-12.

Mahindra P, Yamin M, Selhi H, et al. Chronic Plantar Fasciitis: Effect of platelet-rich plasma, corticosteroid, and placebo. Orthopedics. 2016;39(2): e285-e289.

Matthews BG, Hurn SE, Harding MP, Henry RA, Ware RS. The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton’s neuroma): a systematic review and meta-analysis. J Foot Ankle Res. 2019;12(1):12.

Novitas Solutions. Inc. Local Coverage Determination (LCD): Pain Management of Peripheral Nerves by Injection (L35107). Original Effective Date: 10/01/2015. Revision Effective Date: 10/01/2017. [CMS Website]. Available at: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=35107:16. Accessed July 8, 2021.

Park YH, Lee JW, Choi GW, Kim HJ. Risk factors and the associated cutoff values for failure of corticosteroid injection in treatment of Morton’s neuroma. Int Orthop. 2018;42(2):323-9.

Patacsil JA, McAuliffe M, Feyh LS, et al. Local anesthetic adjuvants providing the longest duration of analgesia for single-injection peripheral nerve blocks in orthopedic surgery: A literature review. AANA J. 2016;84(2).

Perini L, Perini C, Tagliapietra M, et al. Percutaneous alcohol injection under sonographic guidance in Morton’s neuroma: follow-up in 220 treated lesions. Radiol Med. 2016;121(7):597-604.

Urits I, Smoots D, Franscioni H, et al. Injection techniques for common chronic pain conditions of the foot: A Comprehensive Review. Pain Ther. 2020:1-6.

Coding

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

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODES ARE CONSIDERED MEDICALLY NECESSARY WHEN REPORTED WITH 20526 OR 64450:

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 64450 OR 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 WITH 28899 (INJECTION, THERAPEUTIC, TARSAL TUNNEL) OR 64450:

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

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 07.03.27:

03/22/2023	This policy has been reissued in accordance with the Company's annual review process.
05/04/2022	This policy has been reissued in accordance with the Company's annual review process.
12/27/2021	This version of the policy will become effective 12/27/2021. The following new policy has been developed to communicate the Company’s coverage criteria for Pain Management of Peripheral Nerves by Injection.

Version Effective Date:

12/27/2021

Version Issued Date:

12/27/2021

Version Reissued Date:

3/22/2023