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Coverage criteria policies

Peripheral nerve block injections - diabetic peripheral neuropathy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

This procedure is not covered and does not require prior authorization.

The provider and facility will be liable for payment unless:

  1. The provider notifies the member that a specific service/procedure has been determined by HealthPartners to be investigational/experimental; and
  2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

Peripheral nerve blocks or injections for treatment of chronic pain resulting from diabetic peripheral neuropathy are not covered as they are considered investigational. At this time, there is insufficient literature/scientific evidence to support the use of peripheral nerve blocks or injections for peripheral neuropathies caused by underlying systemic diseases.

Definitions

Nerve blocks are injections of anesthetics/steroid near specific nerves.

Neuropathic pain is caused by a dysfunction in the nervous system.

Neuritis refers to the inflammation of a nerve.

Peripheral nerve block is an injection of a local anesthetic, with or without a steroid, into a peripheral nerve (a nerve that connects the central nervous system, including the brain and spinal cord, to sensory organs, such as the eye and ear, as well as to other organs of the body, muscles, blood vessels, and glands) or a nerve cell cluster (ganglion) in an attempt to block pain signals in order to provide prolonged relief from pain.

Peripheral neuropathy refers to damage to the peripheral nervous system.

Peripheral neuropathic pain in diabetes is pain that is a direct consequence of nerve damage associated with high blood sugar in diabetes. The pain most often affects the nerves of the legs and feet.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

64450

Injection, anesthetic agent; other peripheral nerve or branch

ICD-10-CM Codes

Codes

Description

E08.40

Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified

E08.42

Diabetes mellitus due to underlying condition with diabetic polyneuropathy

E09.40

Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified

E09.42

Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy

E10.40

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E10.42

Type 1 diabetes mellitus with diabetic polyneuropathy

E11.40

Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.42

Type 2 diabetes mellitus with diabetic polyneuropathy

E13.40

Other specified diabetes mellitus with diabetic neuropathy, unspecified

E13.42

Other specified diabetes mellitus with diabetic polyneuropathy

G57.90

Unspecified mononeuropathy of unspecified lower limb

G57.91

Unspecified mononeuropathy of right lower limb

G57.92

Unspecified mononeuropathy of left lower limb

G89.29

Other chronic pain

R52

Pain, unspecified

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Academy of Neurology (2011) AAN Summary of Evidence-based Guideline for Clinicians- Treatment of Painful Diabetic Neuropathy. Retrieved from https://www.aan.com/policy-and-guidelines/guidelines/
  2. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. (2010) 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. 112(4):810-33. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775#67949989
  3. Bril, V., England, J., Franklin, G.M., Backonja, M., Cohen, J., Del Toro, D. …Zochodne, D. (2011) Evidence-based guideline: Treatment of painful diabetic neuropathy. American Academy of Neurology. E-Pub ahead of print on April 11, 2011. Retrieved from http://www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.full.pdf
  4. Callaghan, B. , Cheng, H. , Stables, C. , Smith, A. , and Feldman, E. (2012) Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurology 11(6): 521-524.
  5. Feldman, E. and McCulloch, D. Treatment of Diabetic Neuropathy. In: Up To Date, Nathan, D. and Shefner, J. (Ed), Up To Date, Waltham, MA. (Accessed on June 13, 2018).
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Nerve Blocks for the Treatment of Chronic Nonmalignant Pain. Lansdale, PA: Hayes, Inc.; Sept, 2011. Reviewed August, 2015/Archived 2016.
  7. Jeng, C. and Rosenblatt, M. Overview of peripheral nerve blocks. In: UpToDate, Maniker, R. (Ed), UpToDate, Waltham, MA. (Accessed on June 13, 2018).
  8. Mailis, A. and Taenzer, P. (2012) Evidence-based guideline for neuropathic pain interventional treatments: Spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks. Pain Research & Management, 17(3):150-158.
  9. Pop-Busui, R., Boulton, A. J., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., ... & Ziegler, D. (2017). Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes care, 40(1), 136-154.

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Policy activity

  • 03/11/2014 - Date of origin
  • 07/01/2014 - Effective date
Review date
  • 07/2018

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