LCD L37641

Coverage Guidance

Title XVIII of the Social Security Act, §1861(s)(2)(A) and (s)(2)(B) describe coverage benefits for services and supplies ‘incident to’ professional services of the physician.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

CMS Internet-Only Manual, Pub.100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.3 Acupuncture, §30.3.1 Acupuncture for Fibromyalgia, and §30.3.2 Acupuncture for Osteoarthritis.

Indications and Limitations of Coverage

This Local Coverage Determination (LCD) specifically addresses continuous paravertebral, interscalene, supraclavicular, infraclavicular, interscalene brachial plexus, axillary, femoral, lumbar plexus, sciatic, and popliteal (sciatic) nerve blocks.

Background

Out of necessity, multiple continuous peripheral nerve blocks (CPNB) were administered in Operation Iraqi Freedom in 2003. Real-time imaging (portable ultrasound) and peripheral nerve stimulation (PNS) have revolutionized the practice of CPNB anesthesia by providing objective evidence of needle proximity to targeted nerves. In the majority of peripheral nerve blocks (PNB), stimulation of nerves at a current of 0.5 mA or less suggests accurate needle placement for injection of local anesthetic. Differential blockade to achieve pain and temperature block while minimizing motor block can be achieved by using levorotatory enantiomers of local anesthetics and delivering specific concentrations to the nerve. A variety of anesthesia textbooks publish maximum recommended dosages for local anesthetics in an attempt to prevent high dose injections leading to toxicity. Because local anesthetic toxicity is related more to intravascular injection than to total dose, some physicians have suggested maximum dose recommendations are irrelevant. It is reasonable to assume that intravascular injections will occur, and practitioners of regional anesthesia should select techniques designed to minimize their occurrence.

This LCD addresses the use of these blocks in the definition and treatment of pain and conditions primarily treated with nerve blockade, such as complex regional pain syndrome (CRPS) and certain hyperhidroses. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for 3 months or more. CPNB involves the percutaneous insertion of a catheter directly adjacent to a peripheral nerve. The catheter is then infused with local anesthetic resulting in potent, site-specific analgesia that lasts well beyond the normal duration of a single injection nerve block. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency.

Prior to blockade, all patients with pain complaints require an evaluation that includes an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary comprehensive evaluation.

Indications

CPNB may be performed for several reasons and may be covered for the following purposes:

• Therapeutic - to treat painful conditions or hyperhidroses that respond to nerve blocks

• Prognostic - to predict the outcome of long-lasting interventions (e.g., neurolysis, rhizotomy)

Limitations

• CPNB is a physician (or other qualified practitioner) service.

• There is no coverage of CPNB services and supplies ‘incident to’ the professional services of a physician (or other qualified practitioner) in private practice.

• CPNB should be performed with real-time ultrasound imaging and/or PNS to help prevent undesirable side effects such as muscle weakness.

• In general, different types of nerve blocks should not be performed at the same setting as other blocks in the same body region.

• When not used as the primary mode of anesthesia, the medically reasonable and necessary placement of CPNB may be reimbursable. Examples:

• A continuous femoral nerve block placed to provide postoperative analgesia for an anterior cruciate ligament repair or a total knee replacement could be reported separately from the surgical anesthesia.

• For shoulder surgery performed under continuous interscalene brachial plexus block along with a general anesthetic as the primary anesthesia, the block would be separately reportable as long as it will be used for postoperative pain control.

• A continuous brachial plexus block might also provide both the anesthesia and the postoperative pain control for an open reduction of a wrist fracture. Only the anesthesia code would be reported.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

Documentation of the need for CPNB status should be included in the progress notes of each visit/session.

Medical record documentation must support:

• The service was performed by a physician,

• Catheter placement was enhanced with use of imaging and/or nerve stimulation, and

• The medical necessity of CPNB versus other modalities (single injection).

All indications must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

Bibliography

• Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg. 2003;96:247-252.

• Buckenmaier CC, Shields CH, Auton AA, et al. Continuous peripheral nerve block in combat casualties receiving low-molecular weight heparin. British Journal of Anaesthesia. 2006;97:874-877.

• Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009;110(1):182-188.

• Casati A, Fanelli G, Koscielniak-Nielsen Z, et al. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters. Anesth Analg. 2005;101:1192-1197.

• Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: Bacterial colonization, infectious rate and adverse effects. Anesth Analg. 2001;93:1045-1049.

• Di Benedetto P, Casati A, Bertini L, Fanelli G, Chelly JE. Postoperative analgesia with continuous sciatic nerve block after foot surgery: A prospective, randomized comparison between the popliteal and subgluteal approaches. Anesth Analg. 2002;94:996-1000.

• Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: A systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. 2008;100(2):154-164.

• Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology. 2008;108(4):703-713.

• Ilfeld BM, Vandenborne K, Duncan PW, et al. Ambulatory continuous interscalene nerve blocks decrease the time to discharge readiness after total shoulder arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology. 2006;105(5):999-1007.

• Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: A randomized, double-blinded, placebo-controlled study. Anesthesiology. 2002;96(6);1297-1304.

• Ilfeld BM, Le LT, Ramjohn J, et al. The effects of local anesthetic concentration and dose on continuous infraclavicular nerve blocks: A multicenter, randomized, observer-masked, controlled study. Anesth Analg. 2009;108(1):345-350.

• Plunkett AR, Brown DS, Rogers JM, Buckenmaier CC. Supraclavicular continuous peripheral nerve block in a wounded soldier: When ultrasound is the only option. British Journal of Anaesthesia. 2006;97(5):715-717.

• Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opiods? A meta-analysis. Anesth Analg. 2006;102:248-257.

• Swenson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: An experience in 620 patients. Anesth Analg. 2006;103(6):1436-1443.

• Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg. 2007;104(6):1578-1582.

• Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B. A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg. 2006;102:1240-1246.

• Zink W, Bohl JRE, Hacke N, Sinner B, Martin E, Graf BM. The long term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks. Anesth Analg. 2005;101:548-554.