Medical Policy

 

Subject: Peripheral Nerve Blocks for Treatment of Neuropathic Pain
Document #: SURG.00140 Publish Date:    02/28/2018
Status: Reviewed Last Review Date:    01/25/2018

Description/Scope

This document addresses the use of peripheral nerve blocks for the treatment of peripheral neuropathy. This treatment consists of single or multiple injections of a local anesthetic, with or without corticosteroids, into a peripheral nerve or a nerve ganglion. The goal of the peripheral nerve block is to attempt to block pain signals to the brain and provide temporary or prolonged relief from chronic peripheral neuropathic pain of the extremities.

Note: This document does not address nerve blocks for the treatment of nerve entrapment or impingement syndromes such as carpal tunnel or tarsal tunnel syndromes.

Note: This document does not address nerve blocks for the treatment of neuromas, such as Morton’s Neuroma.

Note: Please refer to the following documents for further information regarding the treatment of pain:

Position Statement

Investigational and Not Medically Necessary:

Peripheral nerve blocks are considered investigational and not medically necessary for management of neuropathic pain, including but not limited to treatment of any of the following:

Rationale

There are many causes of peripheral neuropathy. Peripheral nerve blocks for the treatment of peripheral neuropathy involve single or multiple injections of agents or a combination of agents including local anesthetics (such as bupivacaine or lidocaine) with or without corticosteroids into or near peripheral nerves or a nerve ganglion. A peripheral nerve block attempts to block or interrupt the conduction of pain signals to the brain and provide temporary or permanent relief from chronic neuropathic pain conditions.

The peer-reviewed medical literature includes numerous systematic reviews and practice guidelines evaluating the use of nerve blocks for the diagnosis and treatment of neuralgias and neuropathic pain conditions supporting the use of peripheral nerve blockade. However, there is a paucity of well-designed trials and trials with adequate long-term follow-up addressing the use of peripheral nerve blocks for the treatment of peripheral neuropathy.

There are many small case series studies addressing the use of peripheral nerve blocks for a wide variety of neuropathic pain conditions, but their small size and poor methodology limit the generalizability of their conclusions (Arner, 1990; Han, 2007; Mohammed, 2013; Vancaillie, 2012; Vranken, 2000). The largest study is a case study of 3960 subjects with post-herpetic neuralgia treated with Jaipur block involving the use of 2% xylocaine, 0.5% bupivacaine, and 4 mg/mL dexamethasone (Bhargava, 1998). This study found that over a 6-week course of treatment, 28% of subjects had complete relief of pain following a single injection. Another 57% had successful results after a second injection and another 11% after a third injection. Only 4% did not respond to treatment, and these subjects were primarily either over 60 years of age or had long standing pain prior to treatment (greater than 2 years). Sangwan and colleagues (2005) described another case series involving the use of a common peroneal block with 2% xylocaine for the treatment of sciatica due to prolapsed intervertebral disc. A first injection was successful in 175/210 (87%) of subjects. A second injection was successful in the remaining 35 subjects. The authors reported significant improvement in pain, straight-leg lift test, and analgesic consumption.

In the largest randomized controlled trial (RCT) available to date, Ji (2009) enrolled 132 subjects with acute herpes zoster to undergo treatment with either standard therapy with antivirals and analgesics or standard therapy plus repeated paravertebral injections with a mixture of 10 mL 0.25% bupivacaine and 40 mg methylprednisolone every 48 hours for 1 week. Subjects were followed for 1 year, at which time data for 113 (85%) were available (n=58 controls, n=55 injection group). At 1 month, post-herpetic pain was reported in 13% of the injection group vs. 45% in the control group (p<0.001). At 3 and 6 months, post-herpetic neuralgia was significantly improved in the injection group vs. the controls (p<0.001 and p<0.003 respectively). Pain relief was sustained at 1 year (p<0.017).

The next largest available RCT was a double-blind study involving 61 subjects with post-herpetic neuralgia undergoing standard care plus placebo injection (n=30) vs. stellate ganglion block with 0.125% bupivacaine and 8 mg dexamethasone (n=31) (Makharita, 2012). A significantly shorter duration of pain was noted in the experimental group (p=0.002), and the incidence of post-herpetic neuralgia at both 3 and 6 months also significantly favored the experimental group (26.7% vs. 6.5%; p=0.043 and 13.3% vs. 0%; p=0.0035; respectively).

The American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine (2010) published practice guidelines on chronic pain management based on a review of the literature and professional opinion data. Concerning the use of peripheral nerve blocks as a single modality intervention, the guideline states that:

Studies with observational findings for peripheral nerve blocks indicate effective pain relief for assessment periods ranging from 1 to 14 days (Category 2B evidence). There is insufficient evidence to evaluate peripheral nerve blocks for longer periods of time (Category D evidence).

Category B designation is given for “suggestive literature” and level 2 indicates that “the literature contains non-comparative observational studies with associative or descriptive statistics.” Category D designation is given for “insufficient evidence from literature.” The Task Force goes on to say, “Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.” This conclusion is also based on “insufficient evidence to evaluate peripheral nerve blocks for longer periods of time.”

The American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation developed an evidence-based guideline for the treatment of painful peripheral diabetic neuropathy (PDN) (Bril, 2011). A systematic review of the literature was conducted from 1960 to August 2008 with recommendations linked to the strength of the evidence. The guideline reviewed the efficacy of multiple treatments for PDN to reduce pain and improve physical function and quality of life. Effective treatments were identified but the guideline did not discuss the use of peripheral nerve blocks for the treatment of PDN.

In summary, there is insufficient evidence in peer-reviewed medical literature in the form of randomized controlled trials or comparative studies specifically evaluating the use of peripheral nerve blocks for the treatment of peripheral neuropathy, or the underlying systemic diseases that are producing peripheral neuropathy.

Background/Overview

Peripheral neuropathy is a common condition with many possible causes and occurs when nerves are damaged or destroyed, which interferes with the transmission of messages from the brain and spinal cord to other parts of the body.

 

There are many causes of peripheral neuropathy. Diabetic peripheral neuropathy is a type of nerve damage that can occur in individuals with diabetes mellitus as a result of chronic high blood sugar levels that can injure nerve fibers throughout the body. While diabetes and post-herpetic neuralgia (due to herpes viral infection, shingles) are the most common causes of peripheral neuropathy, other causes include, but are not limited to, vitamin deficiency (particularly B12 and folate), alcohol abuse, autoimmune diseases (such as lupus, rheumatoid arthritis or Guillain-Barre syndrome), autoimmune deficiency syndrome (AIDS) (from the disease or its treatment), kidney failure, inherited disorders (such as amyloid polyneuropathy or Charcot-Marie-Tooth disease), exposure to toxins (such as heavy metals, gold compounds, lead, arsenic, mercury, and organophosphate pesticides), chemotherapy agents (such as vincristine) and other medications (such as antibiotics including isoniazid, metronidazole, and statins which have been linked to peripheral neuropathy), and rarely, diseases such as neurofibromatosis. Rare congenital conditions with neuropathies include Fabry disease, Tangier disease, hereditary sensory autonomic neuropathy, and hereditary amyloidosis. Often the etiology is unknown, and this condition is referred to as idiopathic peripheral neuropathy.

 

Peripheral neuropathy can involve different nerve types, including motor, sensory, and autonomic nerves and can also be categorized by the size of the nerve fibers involved, large or small. Chronic symptoms from peripheral neuropathy can include tingling, numbness, unusual sensations, weakness, or burning pain in the affected area.

 

Ideally, treatment for peripheral neuropathy addresses the cause, if known and if a treatment is available. For example, a vitamin deficiency can be corrected. Neuropathies that are associated with immune diseases can improve with treatment of the autoimmune disease. With diabetic peripheral neuropathy the diabetes can be controlled, although control may not reverse the neuropathy.

 

If a specific treatment is not available, neuropathic pain may be relieved with medications, including over-the-counter drugs such as acetaminophen, ibuprofen or aspirin, and in some instances, prescription medications such as tricyclic antidepressants and antiseizure medications. The U.S. Food and Drug Administration (FDA) has approved several drugs for the specific treatment of neuropathy including a prescription patch of 8% capsaicin (Qutenza®) for the treatment of post-herpetic neuralgia. Other FDA approved oral medications include pregabalin (Lyrica®) for the treatment of post-herpetic neuralgia and diabetic peripheral neuropathy, and duloxetine (Cymbalta) for use in the treatment of diabetic peripheral neuropathy. In some instances, opioids may be used to help control the pain that can be associated with peripheral neuropathy. Both Vitamin B6 and alpha-lipoic acid have been used for relief in chemotherapy-induced peripheral neuropathy.

Definitions

Neuropathic pain: Pain that arises as a direct consequence of a lesion or diseases affecting the somatosensory system.

Peripheral neuropathy: Chronic pain resulting from injury to the peripheral nervous system.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

CPT

 

 

64415

Injection, anesthetic agent; brachial plexus, single

 

64417

Injection, anesthetic agent; axillary nerve

 

64447

Injection, anesthetic agent; femoral nerve, single

 

64450

Injection, anesthetic agent; other peripheral nerve

 

64510

Injection, anesthetic agent; stellate ganglion (cervical sympathetic) [for upper extremity pain]

64520

Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) [for lower extremity pain]

ICD-10 Diagnosis

 

B02.23

Postherpetic polyneuropathy

E08.40-E08.49

Diabetes mellitus due to underlying condition with neurological complications

E09.40-E09.49

Drug or chemical induced diabetes mellitus with neurological complications

E10.40-E10.49

Type 1 diabetes mellitus with neurological complications

E11.40-E11.49

Type 2 diabetes mellitus with neurological complications

E13.40-E13.49

Other specified diabetes mellitus with neurological complications

G60.0-G60.9

Hereditary and idiopathic neuropathy

G62.0-G62.9

Other and unspecified polyneuropathies

G63

Polyneuropathy in diseases classified elsewhere

G65.0-G65.2

Sequelae of inflammatory and toxic polyneuropathies

G90.01-G90.09

Idiopathic peripheral autonomic neuropathy

References

Peer Reviewed Publications:

  1. Arnér S, Lindblom U, Meyerson BA, Molander C. Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies. Pain. 1990; 43(3):287-297.
  2. Bhargava R, Bhargava S, Haldia KN, Bhargava P. Jaipur block in postherpetic neuralgia. Int J Dermatol. 1998; 37(6):465-468.
  3. Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008; 62(2):248-254.
  4. Ji G, Niu J, Shi Y, et al. The effectiveness of repetitive paravertebral injections with local anesthetics and steroids for the prevention of postherpetic neuralgia in patients with acute herpes zoster. Anesth Analg. 2009; 109(5):1651-1655.
  5. Makharita MY, Amr YM, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician. 2012; 15(6):467-474.
  6. Mohamed SA, Ahmed DG, Mohamad MF. Chemical neurolysis of the inferior hypogastric plexus for the treatment of cancer-related pelvic and perineal pain. Pain Res Manag. 2013; 18(5):249-252.
  7. Sangwan SS, Mittal R, Kundu ZS, et al. Prolapsed intervertebral disc with sciatica: the role of common peroneal nerve block. Trop Doct. 2005; 35(3):172-174.
  8. Vancaillie T, Eggermont J, Armstrong G, et al. Response to pudendal nerve block in women with pudendal neuralgia. Pain Med. 2012; 13(4):596-603.
  9. Vranken JH, Zuurmond WW, de Lange JJ. Continuous brachial plexus block as treatment for the Pancoast syndrome. Clin J Pain. 2000; 16(4):327-333.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. 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.
  2. Bril V, England J, Franklin GM, et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011; 76(20):1758-1765.
Index

Pain Block

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.

Document History

Status

Date

Action

Reviewed

01/25/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section. 

Reviewed

08/03/2017

MPTAC review. Updated Coding and References sections. 

Reviewed

08/04/2016

MPTAC review. Updated Reference section.

 

06/13/2016

Updated Coding section; removed diagnoses for other mononeuropathies.

 

04/01/2016

Updated Description/Scope. Updated Coding section; removed diagnoses for carpal and tarsal tunnel syndromes.

Reviewed

11/05/2015

MPTAC review. Updated definitions section. Removed ICD-9 codes from Coding section.

New

05/07/2015

MPTAC review. Initial document development.