Medicare Advantage

Medical Policy

Notification

Pain Management of Peripheral Nerves by Injection

Notification Issue Date:

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

Policy statements addressing Medically Necessary and Not Medically Necessary indications were revised for clarity.

Attachment A containing ICD-10 Diagnosis codes that are considered Not Medically Necessary has been removed as it was not an all inclusive list.

Title:

Pain Management of Peripheral Nerves by Injection

Policy #:

MA07.047h

Policy

In the absence of coverage criteria from applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals, or other Medicare coverage documents, this policy uses internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, and/or regulatory status.

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

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 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) - RETIRED. Original Effective Date: 10/01/2015. Revision Effective Date: 12/01/2017. [CMS Website]. Available at: https://localcoverage.cms.gov/mcd_archive/view/lcd.aspx?lcdInfo=35107:16&keyword=L35107&keywordType=starts&areaId=all&docType=6,0,3,5,1,F,P&contractOption=all&dateOption=recent&sortBy=relevance&bc=1. Accessed October 6, 2025.

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 MA07.047h:

11/26/2025	This policy has been reissued in accordance with the Company's annual review process.
10/30/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
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. Policy statements addressing Medically Necessary and Not Medically Necessary indications were revised for clarity. Attachment A containing ICD-10 Diagnosis codes that are considered Not Medically Necessary has been removed as it was not an all inclusive list.

Revisions From MA07.047g:

01/01/2020

This 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

Revisions From MA07.047f:

12/18/2019

This policy has been reissued in accordance with the Company's annual review process.

10/01/2019

This 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

Revisions From MA07.047e:

10/01/2018

This 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

Revisions From MA07.047d:

08/15/2018	This policy has been reissued in accordance with the Company's annual review process.
10/01/2017	This 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

Revisions From MA.07.047c:

05/05/2017

The following criteria have been added to this policy:

Added Attachment A: ICD-10 Codes considered Not Medically Necessary, with CPT code 64450.

Revisions From MA.07.047b:

12/7/2016	This policy was reviewed and reissued to communicate the Company's continuing coverage of pain management of peripheral nerves by injection.
10/01/2016	This 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

Revisions From MA07.047a:

06/01/2016

This 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

Revisions From MA07.047:

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

Version Effective Date:

12/27/2021

Version Issued Date:

12/27/2021

Version Reissued Date:

11/26/2025