About this policy
Jurisdiction: J5 MAC Part B. States: Iowa, Kansas, Missouri, Nebraska. Type: Active LCD
Coverage indications
A. Trigeminal neuralgia Radiofrequency neurolysis (RFN) is considered medically reasonable and necessary for the treatment of trigeminal neuralgia (TN) when ALL the following are met: 1. Condition has been present at least 6 months 53 AND 2. Non-responsive to medical therapy (such as carbamazepine or oxcarbazepine, phenytoin, baclofen) or intolerance of medical therapy 124 AND 3. Patient is not a good surgical candidate or declines surgical intervention 124 AND 4. Patient has had ≥ 75% improvement after diagnostic trigeminal nerve block. Frequency limitation: Limited to (2) Radiofrequency Treatments (RFTs) within a rolling 12 months 42,53 B. Median neuropathy at the wrist, also known as carpal tunnel syndrome (CTS) 1. Corticosteroid (with or without local anesthetic) block may be used for the treatment of CTS. 15 2. Peripheral nerve blocks (PNB) with local anesthetics (LA) only for the treatment of CTS are not medically reasonable and necessary and therefore non-covered. 3. Peripheral nerve denervation for CTS is not reasonable and necessary and therefore non-covered. Frequency: Maximum of 3 steroid injections for CTS may be administered per lifetime per side. 12,13,15,22 C. Morton’s Neuroma 1. Corticosteroid (with or without LA) block may be used for the treatment of Morton’s neuroma 137,138 Frequency: A maximum of 2 steroid injections for Morton’s neuroma may be administered per lifetime per side. 137-139,141 Limitations 1. A PNB involves the use of an anesthetic and/or corticosteroid and does not include injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, dextrose etc.) and/or any other injectates (e.g., vitamins, ozone, etc.). 2. During denervation procedures, patients with implanted electrical devices, (i.e., spinal cord stimulation, peripheral nerve stimulation, cardiac devices, etc.) and intrathecal pump delivery devices, providers should follow manufacturer instructions and extra planning as indicated to ensure safety of the procedure.' 3. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient. 4. PNBs and procedures to treat complex regional pain syndrome, widespread diffuse pain, (i.e., fibromyalgia, myofascial pain, and chronic pain syndrome), or systemic polyneuropathies are investigational and therefore are not considered medically reasonable and necessary. 5. "Dry needling" of neuromas, peripheral nerves are not medically necessary and will be non-covered procedures. 6. It is not routinely necessary for multiple injections or denervation such as epidural steroid injections, facet procedures, trigger point injections (TPI) to be provided to a patient on the same day as peripheral nerve procedures. If performed, the medical necessity of each procedure must be clearly documented in the medical record. It is not reasonable and necessary for therapeutic PNBs, peripheral nerve denervation from ablation (RFA)* or cryoneurolysis for the treatment of: *Peripheral nerve ablation includes thermal RFA, cooled RFA, pulsed RFA, water-cooled RFA and other percutaneous strategies such as balloon compression, glycerol rhizotomy, and microvascular decompression. 1. Occipital nerve block and denervation 2. Stellate ganglion block 3. Trigeminal nerve block 4. Suprascapular nerve block 5. Thoracic nerve block 6. Thoracic nerve denervation 7. Genicular nerve blocks (GNB), cryoneurolysis or ablation 8. Pudendal nerve block 9. Digital nerve block 10. Posterior tibial nerve block at the tarsal tunnel 11. Ulnar nerve block 12. Denervation of the trigeminal nerve for any diagnosis other than TN 13. Any other peripheral nerves blocks or denervations not listed above Exceptions: 1. Regional anesthetic block 2. Acute surgical pain 3. Pain related to malignancy refractory to medical management
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.