Proposed CMS Limits On Peripheral Nerve Blocks For Chronic Pain

Several Medicare Administrative Contractors (MACs) have issued draft Medicare coverage policies regarding peripheral nerve blocks and denervation procedures performed for chronic pain. The proposed local coverage determinations (LCDs) are published through the CMS Medicare Coverage Database and would greatly limit coverage for many of the pain management procedures and treatments provided to Medicare beneficiaries. Several pain medicine organizations, physician groups and patient advocacy groups are working cooperatively to address these changes. They are concerned that these proposed changes in Medicare coverage policy will limit access to non-opioid interventional pain procedures, delay necessary pain management care and direct patients to more costly interventional pain procedures and surgeries, or even to pharmacological pain management with opioids. Specialty groups are meeting with the MACs to address these proposed local coverage determinations and the issue is still under advocacy as of 2026.

Why It Matters

While any Medicare restriction on non opioid pain procedures may largely remain within the confines of coding language, the reality is that chronic pain affects millions of Americans. Data from the CDC found that in 2023, 24.3% of U.S. adults reported experiencing some chronic pain and 8.5% of adults experienced high impact chronic pain which impacted their lives or limited their activity in some way. The numbers increased as people got older. Separate national research found that approximately 37.8% of adults aged 65 years and older reported chronic pain. As a result, any Medicare policy regarding pain management alternatives must be based on accurate information regarding available and effective treatments.

Peripheral nerve blocks serve both diagnostic and therapeutic functions for pain management. Locating the painful generating nerve allows for both short-term pain relief and longer duration pain relief to facilitate sleep, mobilization, and rehabilitation. In addition, the role of corticosteroids for peripheral and sympathetic nerve and blocks was addressed in the recent multisociety evidence-based practice guidelines. This article reviews the practice guidance for the use of corticosteroids for peripheral nerve blocks. Key points in technique, dose, and side effect monitoring are highlighted.

Of particular note, these LCDs are not intended to be a “marginal” issue. Rather, these LCDs will deny payment for many procedures that are used to treat selected chronic pain and associated symptoms in patients of all ages. These procedures are performed by pain specialists and some primary care physicians for the treatment of chronic pain and associated symptoms. While some procedures will still be considered medically reasonable and necessary for the treatment of chronic pain, including regional anesthetic blocks, and some exceptions will be made for acute surgical pain and some malignancy related pain, the scope of chronic pain management for which these services will be considered medically reasonable and necessary will be dramatically reduced. Excluded procedures for which payment will be denied for chronic pain treatment include, but are not limited to: occipital, stellate ganglion, suprascapular, genicular, pudendal, posterior tibial, thoracic and other peripheral nerve blocks and denervations.

For those in the clinical field, there is a great deal of concern regarding access to necessary and effective pain management as well as an intervention that fits. Chronic pain is not a single disease or condition requiring a single management approach and one size fits all solution. Patients with post surgical neuropathic pain, headache related nerve pain, pelvic pain, chronic knee pain, tarsal tunnel pain or complex regional pain (CRPS) do not respond to a step ladder of medication, physical therapy, injections or surgery in a similar fashion. Each of these patient populations require a thoughtful and individualized approach to management and are targeted by specialty organizations. The group of physicians that specialize in pain management have argued that blanket noncoverage of pain management interventions ignores the diagnostic utility of a nerve block as well as the fact that some patients can obtain meaningful functional improvement with repeat targeted interventions.

This policy debate occurs in the context of a growing national effort to promote adoption and use of non opioid pain management strategies. CDC surveillance and NIH research suggest that chronic pain is a major cause of long term disability, often chronic, and can have a substantial impact on quality of life. The stakes are high for both the proponents and opponents of the draft Local Coverage Determinations (LCDs) for minimally invasive nerve directed procedures. Those opposed to the draft LCDs are concerned that limiting use of these procedures could be counterproductive to limiting exposure to opioids that patients and providers do not feel are necessary for their pain management. Additionally, they argue that these types of policies could reduce the ability of clinicians to deliver a range of effective multimodal pain treatments.

In addition to the above policies and comments from our specialty societies and stakeholders, we anticipate that a systems issue will play a role as Local Coverage Determinations (LCDs) will determine which pain management services practices can sustain. Five contractors, including CGS, NGS, Noridian, Palmetto and WPS commented on pain management policies and submitted proposed policies and comments affecting 24 states. This will impact practices, clinics, ambulatory centers and hospital-based pain programs in the potential for denials, appeals, coding and redesign of service lines. Five large MACs weighing in on this single issue will likely establish a patchwork “standard” prior to a national policy.

Who It Affects

The patients with the most to lose in this scenario are those with chronic pain, representing the largest affected group. This includes patients with nerve-mediated pain (e.g. occipital neuralgia, post-surgical neuropathies, pudendal neuralgia, certain knee pain, etc.). They have used targeted nerve injections as a means to help manage their symptoms in order to regain function of activities of daily living, sleep, and work status. Many of these patients have already tried other various options (medications, physical therapy, etc.) and have found conservative management to be insufficient. They will be left without sufficient alternatives if these medications are restricted for patients with complex, chronic pain.

Healthcare providers including anesthesiologists, pain medicine specialists, physiatrists and some surgical specialists will face a host of operational and ethical challenges in successfully navigating the changes to the practice of medicine introduced by the Affordable Care Act. Practices will see a decrease in revenue from a decrease in procedure volume; an increase in administrative tasks to secure prior authorizations and appeals; and the ethical challenges associated with delivery of appropriate care when the care that the physician knows will be best for the patient has been deemed noncovered by payers. These changes to practice also could have an impact on training programs, as well as CME activities.

The changes in how health systems and payers will cover office-based ambulatory surgery (OTB/S) will have important implications for staffing and service lines in both hospitals and ambulatory surgical centers. Private insurers are likely to follow Medicare’s lead in determining coverage. Policymakers and regulators may face challenges in ensuring that expanded coverage does not facilitate overuse and increased fraud while also ensuring access to effective alternatives to opioids and to traditional in-hospital surgical facilities for patients who do not require hospital-level care.

What Changes

• Medicare coverage could be narrowed to exclude many commonly used peripheral nerve block procedures or limit them to a short list of covered indications, reducing payer support for services clinicians currently consider standard care. (\asipp.org\)
• Some proposals would impose limits on the number and timing of repeat injections or denervation procedures, which may force clinicians to alter care plans or seek more invasive or pharmacologic alternatives. (\statnews.com\)
• Specialty societies and professional coalitions are actively contesting draft policies, meeting with Medicare contractors and urging CMS to revise or rescind restrictive drafts; the issue is likely to remain in public comment and advocacy channels in the near term. (\asra.com\)

Clinical and Care Considerations

Peripheral nerve blocks have two roles in clinical practice. Firstly, a peripheral nerve block can be used for a diagnostic role prior to a pain ablation (e.g. radiofrequency or cryoablation) or prior to a pain implant (e.g. spinal cord stimulation, pudendal nerve stimulation, sacral nerve stimulation). Secondly, nerve blocks can provide relief of pain for weeks to months and assist patients in participating in physical rehabilitation programs. Additionally, significant reductions in pain medications with corresponding improvements in function can be achieved.

As benefits of these procedures are very clearly outlined, it is often harder to discuss the potential limitations and rare but potential complications including transient numbness, bleeding, temporary infection, and a rare, permanent nerve injury. New coverage limits will demand more vigorous justification for using these procedures. Very often nonprocedural therapy (medication and lifestyle changes) will be less expensive, so that patients and their physicians will be forced to choose surgery at an earlier point than optimal for their specific situation, based on their goals and overall risk profile.

System-Level and Policy Implications

In order to control costs and prevent over-treatment in the US health system, access to essential clinical services is being challenged. While several Medicare Administrative Contractors (MACs) are developing local coverage determinations (LCDs) on this topic, there are several challenges to achieving consistent coverage for beneficiaries and providers. For example, several MACs are proposing similar but more restrictive LCDs on pain management medications. As a result, the coverage for medications and services provided by doctors and hospitals will differ based on the geographic location of the patient, the doctor, or the hospital. Providers are concerned that this is creating a patchwork of coverage that will prevent the development of evidence-based and standardized pathways for effective pain management.

Where reimbursement policy fails, it can dictate where procedures are delivered—whether it is in a less cost effective outpatient specialty center, an undesirable hospital setting, or worst of all in a non-traditional setting in an extremely cost non-effective and inconvenient manner for the patient. Policymakers must balance fiscal responsibility with some reasonable individual exceptions, a fair appeals process and a timely mechanism for physicians to document medical necessity for those few patients for whom the standard benefit cap does not accurately reflect their medical situation.

Ethical and Equity Considerations

Limiting access to some psychotherapies may not be equitable to certain groups of patients, including patients in rural locations, those who are physically disabled, or of lower socioeconomic status. As a result, patients may have to drive greater distances to receive needed care, wait extended periods of time to be seen by a provider, or be offered less than optimal therapy. When developing a coverage policy for psychotherapies, decision makers must adhere to a number of ethical standards that are sound, transparent, and contain a clear rationale with room for exceptions for indicated treatment of serious mental health conditions. Currently, a number of draft policy statements do not meet these standards.

What Comes Next

Local coverage policies (LCPs) developed by the CMS for various processes and services go through a process of proposal, public comment, and revision. However, specialty societies, patient groups and health systems are now using this same comment process to argue for changes to LCPs to ensure that necessary services are not taken out of scope and left to wither away without reimbursement. Alternatively, they will urge policymakers to limit the scope of any coding changes that do take place, include more clear and robust exceptions and require the Medicare Administrative Contractors (MACs) to adopt local coverage policies that reflect the national guidelines and the clinical consensus of medical experts.

Please pay particular attention to the rulemaking timelines and comment period deadlines for clinical evidence and examples of relevant cases that can be submitted. Patients and advocates can have an impact by sharing their personal stories, especially stories about improvement of function as a result of these procedures. Providers and patients should also be aware of how this will affect documentation requirements and prior authorization procedures.

Final Perspective

A small tweak to Medicare’s payment policy for the reimbursement of chronic pain management could have big consequences for the quality of care that Medicare beneficiaries receive for this common and disabling condition. Future proposals to limit the use of low-value pain medications may inadvertently limit access to non-opioid pain management strategies that help people with chronic pain live with meaningful function. Over the next few months, a final Local Coverage Determination (LCD) will be published that will shape chronic pain management for millions of Medicare beneficiaries for years to come. Now is the time for all stakeholders involved to ensure that a thoughtful, clear, and fair policy is implemented.

References:

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=40264 https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35456