Date Printed: May 27, 2018: 07:34 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.


Original Effective Date: 11/15/00

Reviewed: 03/22/18

Revised: 04/15/18

Subject: Nerve Block Injections


Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    


Nerve blocks consist of injection of a local anesthetic, with or without a steroid, into a peripheral nerve or a nerve ganglion. The anticipated result is temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (sympathetic nerves), to block pain signals and provide prolonged relief from pain.


Sympathetic nerve block injections

Sympathetic nerve block injections meet the definition of medical necessity for the following indications:

Complex regional pain syndrome (CRPS):

Ischemic limb pain:

Pancreatic cancer:

Chronic pancreatitis:

Pelvic/perineal pain:

Ganglion impar blocks of the sacrococcygeal joint are considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this procedure on net health outcomes.

Occipital neuralgia and headache:

Sphenopalatine nerve blocks for the treatment of any condition, including but not limited to occipital neuralgia and headache are considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this procedure on net health outcomes.

Peripheral nerve block injections

Peripheral nerve block injections for the foot meet the definition of medical necessity for the following indications:

Morton’s neuroma:

Plantar fasciitis and other neuritis of the foot:

Imaging (fluoroscopic or ultrasound) for nerve block injections to the foot does not meet the definition of medical necessity.

Occipital neuralgia:

Peripheral nerve block of any occipital or cranial nerve for the treatment of occipital neuralgia, headache, neck pain or other pain is considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this procedure on net health outcomes.

Diabetic neuropathy:

Peripheral nerve block of any nerve for the treatment of diabetic neuropathy is considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this procedure on net health outcomes.

Chronic knee pain:

Nerve block injection of the genicular nerve for the treatment of chronic knee pain is considered experimental or investigational. The available scientific evidence remains insufficient to permit conclusions concerning the effect of this procedure on net health outcomes.

All other peripheral nerve blocks:

Imaging guidance for nerve block injections

Fluoroscopic or ultrasound imaging guidance performed in conjunction with sympathetic or peripheral nerve block injections to isolate the target anatomic site meets the definition of medical necessity (EXCEPTION: injections for the foot, see above).

NOTE: PT, OT or home exercise programs would be continued in addition to nerve block injections as part of a combined treatment plan. It is not expected that epidural blocks, multiple facet joint injections, sacroiliac joint injections, and sympathetic nerve blocks in any and all combinations would be administered to the same individual on the same day. If the first procedure used to treat the presumptive diagnosis fails to produce improvement and rules out that possibility, then it may be appropriate to proceed to the next logical treatment.

Nerve block injections do not meet the definition of medical necessity when medical documentation indicates the injection procedures are not effective.


CPT Coding:


Injection, anesthetic agent; trigeminal nerve, any division or branch


Facial nerve


Injection, anesthetic agent; greater occipital nerve (investigational)


Vagus nerve


Phrenic nerve


Cervical plexus


Brachial plexus, single


Brachial plexus, continuous infusion by catheter (including catheter placement)


Axillary nerve


Suprascapular nerve


Intercostal nerve, single


Intercostal nerve, multiple, regional block


Ilioinguinal, iliohypogastric nerves


Pudendal nerve


Paracervical (uterine) nerve


Sciatic nerve, single


Sciatic nerve, continuous infusion by catheter


Femoral nerve, single


Femoral nerve, continuous infusion by catheter


Lumbar plexus, posterior approach, continuous infusion by catheter


Other peripheral nerve or branch


Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s), e.g., Morton’s neuroma.


Paravertebral block (PVB) (paravertebral block), thoracic single injection site (including imaging guidance, when performed)


Paravertebral block (PVB) (paravertebral block), second and any additional injection site(s) (including imaging guidance, when performed)(List separately in addition to code for primary procedure)


Injection, anesthetic agent; sphenopalatine ganglion (investigational)


Injection, anesthetic agent; stellate ganglion (cervical sympathetic)


Injection, anesthetic agent; superior hypogastric plexus


Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)


Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring

ICD-10 Diagnosis Codes That Support Medical Necessity:

G57.60 – G57.62

Lesion of plantar nerve


Acute pain due to trauma


Acute post-thoracotomy pain


Other acute postprocedural pain

M25.511 – M25.519

Pain in shoulder

M25.521 – M25.529

Pain in elbow

M25.531 – M25.539

Pain in wrist

M25.541, M25.542, M25.549

Pain in joints of hand

M25.551 – M25.559

Pain in hip

M25.561 – M25.569

Pain in knee

M25.571 – M25.579

Pain in ankle

M25.751 – M25.759

Osteophyte, hip

M54.10 – M54.18





Low back pain


Pain in thoracic spine

M70.60 – M70.62

Trochanteric bursitis, hip

M70.70 – M70.72

Other bursitis of hip


Plantar fascial fibromatosis

M75.00 – M75.02

Adhesive capsulitis of shoulder

M76.01 – M76.32

Psoas tendinitis; Iliac crest spur; Iliotibial band syndrome


Neuralgia and neuritis, unspecified

M79.621 – M79.622

Pain in upper arm

M79.631 – M79.632

Pain in forearm

M79.641 – M79.646

Pain in hand and fingers

M79.661 – M79.662

Pain in lower leg

M79.671, 672 – M79.674, 675

Pain in foot and toes

N94.89 – N94.9

Other specified conditions associated with female genital organs and menstrual cycle

Q85.00 – Q85.09

Neurofibromatosis or schwannomatosis


Chest pain on breathing



R10.0 – R10.33

Abdominal and pelvic pain


Other and unspecified symptoms and signs involving the digestive system and abdomen

T87.30 – T87.34

Neuroma of amputation stump


**64400-64402: Total number of injections is limited to four (4) injections in six (6) months.

**64408-64462: Total number of injections is limited to four (4) injections in six (6) months.

**64450: Total number of injections is limited to four (4) injections in six (6) months.

**64510-64530: Total number of injections, in any combination, is limited to three (3) injections in twelve (12) months.

**64455: Total number of injections, in any combination, is limited to three (3) injections in twelve (12) months, per neuroma.

Coding notes:

Per CPT guidelines:

**NOTE: Services in excess of the limitations shown above are subject to medical review of documentation for determination of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes including documentation of conservative treatment, treatment plan, radiology study reports, and operative report.

LOINC Codes:

Documentation Table


LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical



Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note



Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan



Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology report



Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Surgical report



Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.


Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Peripheral Nerve Blocks (L33933), located at


Cervical plexus: a network of nerves made up of the C1, C2, C3, and C4 spinal nerves; innervates the skin and muscles of the head, neck, and shoulders. A nerve block can be performed with a single injection at the C4 transverse process with the local anesthetic spreading to the C2 and C3 nerves.

Morton’s neuroma: a swelling of the nerve present in the space between the third and fourth toes.

Nerve blocks: injection(s) near specific nerves (i.e., certain spinal, peripheral, or other nerves).

Neuritis: Inflammation of a nerve.

Peripheral nerve: any nerve outside the central nervous system.

Plantar fasciitis: inflammation of the band of tissue that connects the heel bone to the toes.

Sphenopalatine ganglion: located in a fossa behind the middle turbinate at the root of the nose and consists of somatosensory, sympathetic, and parasympathetic fibers.

Stellate ganglion: collection of sympathetic nerves in the upper neck on either side of the larynx and is the nerve center for the hand, arms, and shoulders.

Sympathetic nerve: a nerve of the sympathetic nervous system which is part of the autonomic nervous system that is concerned especially with preparing the body to react to situations of stress or emergency, that contains chiefly adrenergic fibers and tends to depress secretion, decrease the tone and contractility of smooth muscle, increase heart rate, and that consists essentially of preganglionic fibers arising in the thoracic and upper lumbar parts of the spinal cord and passing through delicate white rami communicates to ganglia located in a pair of sympathetic chains situated one on each side of the spinal column or to more peripheral ganglia or ganglionated plexuses and postganglionic fibers passing typically through gray rami communicates to spinal nerves with which they are distributed to various end organs.


Neurolysis/Ablation, 02-61000-34


None applicable.


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This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/22/18.



Outpatient Pain Management MCG #02-61000-01 approved by MPCC.


Separate MCG created for Nerve Block Injections.


Annual HCPCS coding update.


Scheduled review and revision of guideline consisting of updated references.


Review and revision of guideline consisting of updated references and addition of diagnosis codes.


Annual HCPCS coding update: revised descriptor for codes 64416, 64446, 64448 and 64449.


Scheduled review; update description section to include medical necessity management statement, update position statement to include coverage criteria, update reimbursement statement and references.


Revision; added coverage criteria for peripheral nerve block injections for conditions of the foot; added CPT code 64455; added ICD-9 codes 355.5, 355.79 and 728.71; added related ICD-10 codes; revised reimbursement section; added coding notes; updated definitions section; updated references; reformatted guideline.


Revision; formatting changes.


Scheduled review; revised description, added coverage criteria for pre-emptive analgesia to position statement, revised ICD9 and ICD10 coding sections; added Medicare program exception; updated references; reformatted guideline.


Revision. Added coverage statement for CPT 64405, occipital nerve blocks (E/I). Added coverage statement for ganglion impar blocks of the sacrococcygeal joint (E/I). Added criteria for ”other peripheral nerve blocks”. Updated references and reformatted guideline. Deleted CPT code 64405. Deleted ICD9 codes 307.81, 564.6, 569.42 and 784.0; deleted ICD10 codes G44.00—G44.89, G44.201-G44.229, K59.4, K62.81-K62.82 and R51.


Revision; updated ICD10 coding with new and revised codes.


Revision; added CPT code 64405 back to the guideline with an investigational tag (designated as investigational on 02/15/12). Revised Position Statement verbiage regarding greater occipital nerve blocks. Revised Reimbursement Information section.


Revision; revised description statement and position statement (designated sphenopalantine ganglion block as E/I). Updated program exceptions section and references. Reformatted guideline.


Revision; added coverage statement for nerve block injections for the treatment of diabetic neuropathy (E/I). Reformatted guideline.


Revision; updated ICD9 and ICD10 coding sections.


Revision: ICD-9 Codes deleted.


Annual CPT/HCPCS coding update. Added codes 64461, 64462. Deleted code 64412. Revised Reimbursement Information section and Programs Exception section.


Revision: Update to Position Statement and ICD-10 codes.


ICD-10 coding update: added codes M25.541, M25.542, M25.549.


Revision: Update to Reimbursement Information section.


Scheduled review. Revised description section. Added coverage statement for imaging guidance for nerve block injections; added coverage statement for genicular nerve blocks (E/I). Revised Medicare Advantage program exception. Updated references.

Date Printed: May 27, 2018: 07:34 PM