November 25, 2025
3 min read
Key takeaways:
- Multiple Medicare Administrative Contractors have proposed to restrict coverage for peripheral nerve block procedures.
- Many medical societies are speaking out against the proposal.
Multiple Medicare administrative contractors have proposed local carrier determinations that would restrict coverage for many evidence-based procedures used in chronic pain management, according to a press release.
By incorporating new procedures and literature, CMS said the local carrier determinations (LCDs) would expand Medicare coverage to include radiofrequency neurolysis for refractory trigeminal neuralgia, corticosteroid injections for carpal tunnel syndrome, corticosteroid injections for Morton’s neuroma and diagnostic nerve blocks.
“The proposed policy seeks to ensure that Medicare beneficiaries have access to treatments that have demonstrated clinical benefit and improved patient outcomes based on current medical evidence and clinical best practices,” CMS told Healio.
Medicare restrictions
In addition to expanding coverage for certain pain management procedures, the LCD also states that therapeutic peripheral nerve blocks, peripheral nerve denervation from ablation or cryoneurolysis are “not reasonable or necessary” for the treatment of:
- occipital nerve block and denervation;
- stellate ganglion block;
- trigeminal nerve block;
- suprascapular nerve block;
- thoracic nerve block;
- thoracic nerve denervation;
- genicular nerve blocks, cryoneurolysis or ablation;
- pudendal nerve block;
- digital nerve block;
- posterior tibial nerve block at the tarsal tunnel;
- ulnar nerve block;
- denervation of the trigeminal nerve for any diagnosis other than trigeminal neuralgia; and
- any other peripheral nerve blocks or denervation not listed above.
The exceptions to this list include regional anesthetic block, acute surgical pain and pain related to malignancy refractory to medical management, according to CMS.
But many medical societies, such as the American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons, American Academy of Pain Medicine and others, have expressed concern regarding this proposal and the possibility that it could increase reliance on opioids.
Adam J. Bruggeman
“Orthopedic surgeons are working diligently to properly manage their patients’ pain while, when clinically appropriate, reducing the use of opioids in treatment,” Adam J. Bruggeman, MD, MHA, FAAOS, FAOA, chair of the AAOS Advocacy Council and orthopedic spine surgeon at the Texas Spine Care Center in San Antonio, Texas, told Healio. “The nonopioid treatments covered by the LCD are important options that should be available to patients. This is why we are asking the [Medicare administrative contractors] to rescind the proposed LCD or, at a minimum, postpone the issuance of the proposed LCD and work with medical societies to develop an evidence-based LCD that more accurately reflects current research and clinical considerations.”
‘Slippery slope’
Although some of the procedures may have data that is underpowered, Philip J. Koehler III, DO, MS, FAAPMR, DABPM, said these procedures still benefit patients who suffer from rare pain conditions with limited treatments.
“A lot of these patients getting nerve block procedures have failed a lot of conservative treatment already,” Koehler, attending physician in the department of physical medicine and rehabilitation at Rothman Orthopaedics, told Healio. “They failed therapy, neuroleptic medications, pain psychology and desensitization therapy. It is not your first-line treatment when you have these types of procedures. It is for patients who have been refractory to your conservative care.”
Koehler said one worry is that the restriction of some of these peripheral nerve block procedures may affect similar, more standard procedures, leaving patients to undergo more invasive and costly procedures instead.
“It’s just a slippery slope for restricting access to care, and then patients end up getting more aggressive treatments that are still covered,” Koehler said. “You went from a minimally invasive procedure that can provide long-term pain relief for patients to now patients getting surgical procedures that are costly and, oftentimes, don’t have the evidence to back it.”
Koehler said the question is then, “What do you do for these patients when you don’t have access to these procedures?”
“It’s discouraging when you’re seeing a lot of patients who are living longer and who are trying to remain functional having access to care stripped from them,” Koehler said. “My elderly patients don’t do well with medications and opioids. They have significant side effects and significant risks. [Coverage restrictions] like this are disappointing to those patients and my concern is, eventually, what options are they going to have when Medicare isn’t covering these procedures for them? And what is it going to mean for physicians in private practice?”
For more information:
Adam J. Bruggeman, MD, wishes to be contacted through media@aaos.org.
Philip J. Koehler III, DO, MS, FAAPMR, DABPM, can be contacted at philip.koehler@rothmanortho.com.
Sources/Disclosures
Source:
Healio Interviews
References:
Disclosures:
Bruggeman and Koehler report no relevant financial disclosures.
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