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Clinical Policy Bulletin:
Peripheral Nerve Blocks
Number: 0863


Policy

Aetna considers the use of peripheral nerve blocks (continuous or single-injection) medically necessary for the treatment of (i) acute pain, and (ii) for chronic pain only as part of an active component of a comprehensive pain management program. Peripheral nerve blocks as sole treatment for chronic pain is considered experimental and investigational.

Aetna considers treatment of chronic pain post herniorrhaphy with a nerve block medically necessary to avoid more aggressive treatments, such as, surgery.

Aetna considers intercostal nerve blocks experimental and investigational for the sole treatment of chronic intercostal neuritis because there is no clinical evidence to support the use of intercostal nerve blocks in the treatment of chronic intercostal neuritis. Intercostal nerve blocks are considered medically necessary for acute intercostal pain, and for chronic intercostal neuritis as part of a comprehensive pain management program.

Aetna considers suprascapular nerve blocks experimental and investigational in the treatment of chronic upper extremity pain because the clinical evidence is not sufficient to permit conclusions on the health outcome effects of a suprascapular nerve block in the treatment of upper extremity pain.

See also CPB 0722 - Selective Nerve Root Blocks, and CPB 0729 - Diabetic Neuropathy: Selected Treatments.



Background

A nerve block is a form of regional anesthesia. Peripheral nerve blocks (PNBs) entail the injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (somatic and sympathetic nerves).  Peripheral nerve blocks can either be “single-injection” -- refers to one-time injection of local anesthetic to the target nerve for peri-operative analgesia and/or surgical anesthesia, or “continuous” -- refers to the percutaneous insertion of a catheter directly adjacent to the target peripheral nerve(s).  The latter approach is to provide prolonged nerve block by continuous infusion of local anesthetic for longer procedures, as well as post-operative analgesia.  Continuous PNB (cPNB) is primarily used for inpatient procedures, but can also be used in outpatients (Jeng and Rosenblatt, 2012).

Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system. Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions some that can cause neuropathic pain of the extremities are diabetic neuropathy, reflex sympathetic dystrophy syndrome, phantom limb and post-amputation pain. Chronic pain persists over a longer period of time than acute pain and is resistant to most medical treatments. A peripheral nerve block may be performed to diagnose and/or treat neuropathic pain.

Aguirre et al (2012) stated that the most common use of cPNBs is in the peri- and post-operative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain.  The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of post-operative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of post-surgical chronic pain and reduction of costs.  Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate post-operative effects.  Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life (QOL) measures is still lacking.

In a review on “Evidence-based interventions for chemotherapy-induced peripheral neuropathy”, Visovsky et al (2007) examined the literature on the prevention or treatment of chemotherapy-induced peripheral neuropathy (CIPN), which included pilot studies, clinical trials, systematic reviews of the literature, and case studies.  The Oncology Nursing Society Putting Evidence Into Practice® (PEP) CIPN Team consisted of 2 advanced practice nurses, 2 staff nurses, and a nurse researcher.  The CIPN Team chose not to include animal model-based studies because applicability and generalizability to human populations has not been established.  No meta-analyses addressing the prevention or treatment of CIPN were found in the literature.  The team searched Medline, the National Library of Medicine's database.  Search terms included chemotherapy-induced peripheral neuropathy, peripheral neuropathy, and neuropathy.  Search terms specific to known CIPN interventions also were explored, including human leukemia inhibitory factor, nerve growth factor, neurotrophin-3, exercise and chemotherapy-induced peripheral neuropathy, exercise and neuropathy, diabetes and peripheral neuropathy, vitamin E, tricyclic antidepressants (TCAs), amifostine, calcium/magnesium infusions, carbamazepine, glutathione, alpha lipoic acid, and glutamine.  Other search terms were alternative therapy, complementary therapies, herbal therapies, plants-medicinal, herb(s), herbal(s), acupuncture, electric nerve stimulation, high-frequency external muscle stimulation, transelectrical nerve stimulation, spinal cord stimulation, anodyne therapy, pulsed infrared light therapy, social support, psychosocial support, educational interventions, patient education, patient safety, safety, injury, accidents, safety management, protective devices, and capsaicin.  The authors concluded that CIPN remains a significant problem for patients receiving chemotherapy for cancer.  At present, no interventions for CIPN can be recommended for practice.  No rigorously designed studies, meta-analyses, or systematic reviews support any of the interventions discussed, and risk of harm may out-weigh potential benefits.

The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine’s practice guidelines on “Chronic pain management” (2010) stated that “Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain”.

Hartemann et al (2011) stated that the prevalence of painful diabetic neuropathy (PDN) is approximately 20 % in patients with type-2 diabetes and 5 % in those with type-1 diabetes.  Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers.  As PDN is due to small-fiber injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal.  Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness).  The DN4 questionnaire is an easy-to-use validated diagnostic tool.  Three classes of drugs are of equal value in treating PDN: (i) TCAs; (ii) anticonvulsants; and (iii) selective serotonin-reuptake inhibitors (SSRIs).  These compounds may be prescribed as first-line therapy following pain assessment using a visual analog scale (VAS).  If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30 %, another drug class should be prescribed; if the pain is decreased by 30 % but remains greater than 3/10, a drug from a different class may be given in combination.

The American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation (Bril et al, 2011) developed a scientifically sound and clinically relevant evidence-based guideline for the treatment of PDN.  The basic question that was asked was: "What is the efficacy of a given treatment (pharmacological: anticonvulsants, antidepressants, opioids, others; non-pharmacological: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others) to reduce pain and improve physical function and QOL in patients with PDN"?  A systematic review of literature from 1960 to August 2008 was performed, and studies were classified according to the AAN classification of evidence scheme for a therapeutic article.  Recommendations were linked to the strength of the evidence.  The results indicated that pregabalin is established as effective and should be offered for relief of PDN (Level A).  Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulfate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B).  Other treatments have less robust evidence, or the evidence is negative.  Effective treatments for PDN are available, but many have side effects that limit their usefulness.  Few studies have sufficient information on their effects on function and QOL.

The South African Expert Panel’s clinical practice guidelines for management of neuropathic pain (Chetty et al, 2012) stated that neuropathic pain (NeuP) is challenging to diagnose and manage, despite ongoing improved understanding of the underlying mechanisms.  Many patients do not respond satisfactorily to existing treatments.  There are no published guidelines for diagnosis or management of NeuP in South Africa.  A multi-disciplinary expert panel critically reviewed available evidence to provide consensus recommendations for diagnosis and management of NeuP in South Africa.  Following accurate diagnosis of NeuP, pregabalin, gabapentin, low-dose TCAs (e.g., amitriptyline) and SSRIs (e.g., duloxetine and venlafaxine) are all recommended as first-line options for the treatment of peripheral NeuP.  If the response is insufficient after 2 to 4 weeks, the recommended next step is to switch to a different class, or combine different classes of agent.  Opioids should be reserved for use later in the treatment pathway, if switching drugs and combination therapy fails.  For central NeuP, pregabalin or amitriptyline are recommended as first-line agents.  Companion treatments (e.g., cognitive behavioral therapy and physical therapy) should be administered as part of a multi-disciplinary approach.  Dorsal root entry zone rhizotomy (DREZ) is not recommended to treat NeuP. 

In an evidence-based guideline on “Neuropathic pain interventional treatments”, Mailis and Taenzer (2012) states that “Based on limited evidence that selective transforaminal nerve root blocks (extraforaminal root injections, periradicular steroid injections, intraforaminal oxygen-ozone injections and epidural perineural autologous conditioned serum injections can provide up to 8 to 12 weeks of relief from lumbar radicular pain, the task force cannot justify a general recommendation, but suggests that these interventions be used with caution depending on the circumstances, with full disclosure to the patient of the limited evidence and potential risks.  Evidence quality: Fair; Certainty: Moderate; Strength of recommendation: Grade C (May recommend depending on circumstances.  At least moderate certainty with small net benefit).

Furthermore, UpToDate reviews on “Treatment of diabetic neuropathy” (Feldman and McCulloch, 2012), “Overview of lower extremity peripheral nerve syndromes” (Rutkove, 2012), and “Epidemiology, clinical manifestations, diagnosis, and treatment of HIV-associated peripheral neuropathy” (Nardin and Freeman, 2012) do not mention the use of PNBs.

Ashkenazi et al (2010) stated that interventional procedures such as PNBs and trigger point injections (TPIs) have long been used in the treatment of various headache disorders.  There are, however, little data on their effectiveness for the treatment of specific headache syndromes.  Moreover, there is no widely accepted agreement among headache specialists as to the optimal technique of injection, type, and doses of the local anesthetics used, and injection regimens.  The role of corticosteroids in this setting is also being debated.  These investigators performed a PubMed search of the literature to find studies on PNBs and TPIs for the treatment of headaches.  They classified the abstracted studies based on the procedure performed and the treated condition.  These researchers found few controlled studies on the effectiveness of PNBs for headaches, and virtually none on the use of TPIs for this indication.  The most widely examined procedure in this setting was greater occipital nerve block, with the majority of studies being small and non-controlled.  The techniques, as well as the type and doses of local anesthetics used for PNBs, varied greatly among studies.  The specific conditions treated also varied, and included both primary (e.g., migraine, cluster headache) and secondary (e.g., cervicogenic, post-traumatic) headache disorders.  Trigeminal (e.g., supraorbital) nerve blocks were used in few studies.  Results were generally positive, but should be taken with reservation given the methodological limitations of the available studies.  The procedures were generally well-tolerated.  The authors concluded that there is a need to perform more rigorous clinical trials to clarify the role of PNBs and TPIs in the management of various headache disorders, and to aim at standardizing the techniques used for the various procedures in this setting.

In summary, there is currently insufficient evidence to support the use of peripheral nerve blocks in the treatment of peripheral neuropathy or other indications.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Peripheral Nerve Blocks :
CPT codes covered if selection criteria are met:
64400 - 64450
ICD-9 codes covered if selection criteria are met:
338.11 - 338.19 Acute pain
338.21 - 338.28 Chronic pain
Chronic Pain Post Herniorrhaphy:
CPT codes covered if selection criteria are met:
64425
ICD-9 codes covered if selection criteria are met (not all inclusive):
550.00 - 553.9 Hernia of abdominal cavity
Intercostal Nerve Blocks:
CPT codes not covered for indications listed in the CPB:
64420 - 64421
ICD-9 codes not covered for indications listed in the CPB (not all inclusive):
353.8 Other nerve root and plexus disorders [intercostal neuritis]
Suprascapular Nerve Blocks:
CPT codes not covered for indications listed in the CPB :
64418
ICD-9 codes not covered for indications listed in the CPB (not all inclusive):
729.5 Limb pain


The above policy is based on the following references:
  1. Visovsky C, Collins M, Abbott L, et al. Putting evidence into practice: Evidence-based interventions for chemotherapy-induced peripheral neuropathy. Clin J Oncol Nurs 2007;11(6):901-913. Available at: http://www.guideline.gov/content.aspx?id=15703&search=peripheral+neuropathy. Accessed December 18, 2012.
  2. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010;112(4):810-833. Available at: http://www.guideline.gov/content.aspx?id=23845&search=nerve+block. Accessed Accessed December 18, 2012.
  3. Ashkenazi A, Blumenfeld A, Napchan U, et al; Interventional Procedures Special Interest Section of the American. Peripheral nerve blocks and trigger point injections in headache management - a systematic review and suggestions for future research. Headache. 2010;50(6):943-952.
  4. Hartemann A, Attal N, Bouhassira D, et al; Working Group on the Diabetic Foot from the French-speaking Society of Diabetology. Painful diabetic neuropathy: Diagnosis and management. Diabetes Metab. 2011;37(5):377-388.
  5. Bril V, England JD, Franklin GM, et al; American Academy of Neurology; American Asociation of Neuromuscular and Electrodiagnostic Medicine; American Academy of Physical Medicine and Rehabilitation. Evidence-based guideline: Treatment of painful diabetic neuropathy -- report of the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Neurology, and the American Academy of Physical Medicine & Rehabilitation. Muscle Nerve. 2011;43(6):910-917.
  6. Jeng CL, Rosenblatt MA. Overview of peripheral nerve blocks. Last reviewed November 2012. UpToDate Inc. Waltham, MA.
  7. Aguirre J, Del Moral A, Cobo I, et al. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:560879.
  8. Chetty S, Baalbergen E, Bhigjee AI, et al; South African Expert Panel. Clinical practice guidelines for management of neuropathic pain: Expert panel recommendations for South Africa. S Afr Med J. 2012;102(5):312-325.
  9. Mailis A, Taenzer P. Evidence-based guideline for neuropathic pain interventional treatments: Spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. Pain Res Manag. 2012;17(3):150-158.
  10. Feldman EL, McCulloch DK. Treatment of diabetic neuropathy. Last reviewed November 2012. UpToDate Inc. Waltham, MA.
  11. Rutkove SB. Overview of lower extremity peripheral nerve syndromes. Last reviewed November 2012. UpToDate Inc. Waltham, MA.
  12. Nardin RA, Freeman R. Epidemiology, clinical manifestations, diagnosis, and treatment of HIV-associated peripheral neuropathy. Last reviewed November 2012. UpToDate Inc. Waltham, MA.
  13. Abram SE. Neural blockade for neuropathic pain. Clin J Pain, 16(2 Suppl): S56-61   2000.
  14. Eker HE et al. Management of neuropathic pain with methylprednisolone at the site of nerve injury. Pain Medicine: The Official Journal of the American Academy of Pain Medicine, Vol 13, Iss 3  2012.
  15. Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology, 112(4): 810-33  2010.
  16. Kliegman: Nelson Textbook of Pediatrics. Nineteenth Edition. 2011.
  17. Miller: Miller's Anesthesia. Seventh Edition. 2009.
  18. Varrassi G et al. Neural modulation by blocks and infusions. Pain Pract, 6(1): 34-8   2006.
  19. Vlassakov KV et al. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis. Anesth Analg; 112(6): 1487-93  2011.
  20. Williams BA; Murinson BB. Diabetes mellitus and subclinical neuropathy: a call for new paths in peripheral nerve block research. Anesthesiology, 109(3)  2008.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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