A Significant Change
Late last month, several Medicare administrative contractors (MACs) published a proposed Local Coverage Determination (LCD), i.e., medical policy, that would essentially strip away providers’ ability to bill for multiple types of peripheral nerve blocks. In fact, according to a press release from the American Society of Interventional Pain Physicians (ASIPP), this proposed LCD would mean the “elimination of almost all peripheral nerve blocks from coverage.”
The MACs that have so far published this proposed change in policy include CGS, NGS, Noridian, Palmetto and WPS. Novitas and First Coast Service Options have yet to release their versions of the proposed LCD. However, we expect these MACs to publish a similar proposed policy in the near future. And make no mistake; this will be a game-changer.
The Proposed Particulars
The proposed LCDs that have already been published essentially provide for the following:
- As it pertains to peripheral nerve blocks, “Coverage is provided only for radiofrequency neurolysis for trigeminal neuralgia (limited to 2 RFTs in a rolling 12 month), corticosteroid injections for median neuropathy at the wrist (limited to a maximum of three injections per lifetime per side) and corticosteroid injections for Morton’s neuroma (limited to a maximum of two injections per lifetime per side).”
- “All other peripheral nerve block and related procedures are not covered,” i.e., not payable, under these policies, to include the following:
- Occipital nerve block and denervation
- Stellate ganglion block
- Trigeminal nerve block
- Suprascapular nerve block
- Thoracic nerve block
- Thoracic nerve denervation
- Genicular nerve blocks (GNB), cryoneurolysis or ablation
- Pudendal nerve block
- Digital nerve block
- Posterior tibial nerve block at the tarsal tunnel
- Ulnar nerve block
- Denervation of the trigeminal nerve for any diagnosis other than TN
- Any other peripheral nerves blocks, or denervation not listed above
- PNBs and procedures to treat complex regional pain syndrome, widespread diffuse pain, (i.e., fibromyablgia, myofascial pain, and chronic pain syndrome), or systemic polyneuropathies are investigational and therefore are not considered medically reasonable and necessary.
On a more positive note, facet joint interventions and epidural procedures remain covered and payable.
Now, obviously, this is going to be a hit to chronic pain practices first and foremost. Granted, the above-listed block procedures are not particularly common; but many interventional pain physicians like to keep their options open, and now those options are closed to that category of providers. But what about anesthesia providers? Is there anything in the proposed LCDs that might cause them concern?
Here's a direct quote from the LCD:
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.
Based on the context of this quote, “these procedures” refer specifically to peripheral nerve blocks. So, generally speaking, an anesthesia claim in connection with a chronic pain doctor’s peripheral nerve block injection would be denied unless documentation is provided indicating medical necessity. But since most of these underlying nerve block procedures will no longer be paid by Medicare, the associated anesthesia service would also be denied.
The good news for anesthesia providers is that the non-coverage of peripheral nerve blocks only extends to the chronic pain context. When it comes to acute pain—such as in an anesthesia case, the anesthesia provider may still place and get paid for such blocks. This is from the LCD:
Exceptions:
- Regional anesthetic block
- Acute surgical pain
- Pain related to malignancy refractory to medical management
The “exceptions” to the otherwise non-coverage of peripheral nerve blocks, as listed above, mean that anesthesia providers can still use such blocks as a regional anesthetic or for postoperative pain management.
A Call to Action
There is still time to change Medicare’s position on this proposed policy. Public comments are open until November 8 for CGS, NGS, Noridian, and Palmetto, and until November 22 for WPS.
Comments may be submitted directly through each Medicare Administrative Contractor (MAC) by using the links provided below:
If you have questions about this article, please contact your account executive.