Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

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).

 Pain management of peripheral nerves by injection may be considered medically necessary for ANY of the following indications:

·       Carpal tunnel injection indications:

o   Individuals with pain and paresthesia radiating to the forearm, and elbow; or

o   Individual has failed conservative measures such as orthoses, oral agents or are contraindicated; or

o   As adjunctive therapy to systemic agents for an inflammatory arthritis when those agents have not yet become effective and the patient experiences a relative entrapment syndrome manifested by moderate to severe pain; or

o   Weakness in the median nerve distribution. 

·       Tarsal tunnel syndrome (without history of trauma):

• Individuals that have failed conservative measures such as but not limited to:
  •  Shoe modification; or
  •   Orthotics; or
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
•     Plantar fasciitis injections indications:
  •    Individual that has failed conservative measures( within two to three months) such as but not limited to:
    •   Stretching exercises for the plantar fascia and calf muscles done at home; or
    •  Avoidance of use of flat shoes and walking barefoot; or
    •   Use of prefabricated, over-the-counter, silicone heel shoe inserts; or
    •   Short-term trial (two to three weeks) of nonsteroidal anti-inflammatory drugs (NSAIDS);or
    •   Injecting the tender areas of the plantar regions with glucocorticoids and a local anesthetic; or
    • Activity modification

When ultrasound guidance is reported, only one (1) unit of service will be reimbursed per date of service per provider.

The signs or symptoms that justify peripheral nerve blocks should be resolved after one (1) to (4) injections at a specific site. Injections beyond three (4) per benefit period year are considered not medically necessary.

Injections of more than two (2) sites at one (1) session or for frequent or repeated injections is considered not medically necessary.

"Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths and their origins/insertions is considered not medically necessary.

Acupuncture is not to be billed with the procedure codes in this policy. Acupuncture with or without subsequent electrical stimulation is considered not medically necessary.

  Neuromas

·       Short-term Injections of local anesthetics and/or steroids into interdigital neuromas (Morton’s, Heuter’s, Hauser’s, and Iselin’s) may be considered medically necessary to relieve pain or dysfunction resulting from inflammation or other pathological changes

·       Alcohol injection into interdigital neuromas (Morton’s, Heuter’s, Hauser’s, and Iselin’s) for the treatment of peripheral nerve pain is considered experimental/investigational; and therefore, noncovered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

·       Short-term injections of local anesthetics first and then if effective, a neurolytic agent such as phenol into post-amputee neuromas may be considered medically necessary to relieve pain.

Neurolytic agents, local anesthetics, or steroid injections not meeting the criteria as indicated in this policy are considered not medically necessary.

  Trigger Point Injections

Trigger point injections with anesthetic and/or corticosteroid may be considered medically necessary for the treatment of myofascial pain syndrome when ALL the following criteria have been met:

·       There is a regional pain complaint in the expected distribution of referral pain from a trigger point; and

·       There is spot tenderness in a palpable taut band in a muscle; and

·       There is restricted range of motion; and

·       Conservative therapy (i.e., physical therapy, active exercises, ultrasound, heating or cooling, massage, activity modification, or pharmacotherapy) for six (6) weeks fails or is not feasible; and

·       Trigger point injections are provided as a component of a comprehensive therapy program.

Trigger point injections beyond twelve (12) per benefit year are considered not medically necessary.

Trigger point injections not meeting the criteria as indicated in this policy are considered not medically necessary.

 Occipital Nerve Blocks

Occipital nerve blocks with anesthetic and/or corticosteroid may be considered medically necessary for the treatment for ANY of the following conditions:

·       Occipital neuralgia; or

·       Cervicogenic headache; or

·       Migraine; or

·       Cluster headache.

Occipital nerve blocks with anesthetic may be performed every four to six (4-6) weeks if clinically indicated. The individual must receive at least 51% or greater benefit from the occipital nerve block prior to repeat procedure. Occipital nerve blocks with anesthetic beyond twelve (12) per benefit year are considered not medically necessary.

Occipital nerve blocks with corticosteroids may be performed every three (3) months if clinically indicated. The individual must receive at least 51% or greater benefit from the occipital nerve block prior to repeat procedure. Occipital nerve blocks with corticosteroids beyond four (4) per benefit year are considered not medically necessary.

Please note an individual may receive a MAXIMUM of twelve (12) occipital blocks per benefit year (in any combination of anesthetic and/or corticosteroid). Occipital nerve blocks with corticosteroids and/or anesthetics beyond twelve (12) per benefit year are considered not medically necessary.

Occipital nerve blocks not meeting the criteria as indicated in this policy are considered not medically necessary.