Peripheral nerve injections under the new Medicare LCDs
Five Medicare contractors now share one policy for peripheral nerve injections and denervation for chronic pain. This page shows which policy applies to you, what is covered, the criteria to document, and what remains non-covered.
Which policy applies to your practice?
Coverage follows the MAC that processes your Part B claims. Choose your state, or tap a contractor.
Coverage by nerve target
The five LCDs are substantively identical. Open any row for the criteria, limits and codes. A therapeutic injection or denervation not listed as covered is non-covered.
Genicular nerve ablation: does this patient qualify?
Work through the LCD criteria in order. The checker tracks what is documented and flags the exclusions that stop the pathway.
Universal limits, documentation and billing
Limits in every section
- Chronic pain means ≥12 weeks from onset. Acute, surgical and perioperative pain, regional anesthesia and refractory cancer pain are out of scope.
- Injectate is local anesthetic with or without steroid. PRP, amniotic or placental products, dextrose, ozone and vitamins are non-covered and can deny the whole claim.
- Moderate or deep sedation, general anesthesia or MAC for nerve injections is not reasonable and necessary except in documented exceptional cases.
- Same-day ESI, facet, trigger point or denervation work needs its own documented necessity.
- Fibromyalgia, myofascial pain, chronic pain syndrome and systemic polyneuropathy are investigational. Dry needling and electrical stimulation during an injection are non-covered.
- Image guidance for a non-covered injection is also non-covered.
Documentation the MACs will look for
- Informed consent that names the risk of nerve injury and worsening pain.
- Diagnostic blocks: pre- and post-procedure pain on the same standardized scale, recorded for the expected duration of the anesthetic.
- Ultrasound: at least one stored image of the needle at target.
- Fluoroscopic ablation: nerves targeted, AP / oblique / lateral views, contrast confirmation, sensory-motor testing, fluoro time and dose, lesion temperature and duration.
- Baseline pain and disability scale (for example NRS plus WOMAC or KOOS) before genicular work.
Billing article highlights
KXon the initial diagnostic injection. Repeat diagnostic blocks of the same nerve are not billable, except a second genicular block.- One diagnostic session per peripheral nerve, whatever code is billed.
64454covers SM, SL and IM branches; inject fewer and append52.- Bilateral:
50on professional claims; ASC facility claims bill two lines withRT/LT. - Do not add
77002/77003with59when imaging is bundled into the code. - CPT and ICD-10 lists live in each MAC's billing article, not the LCD.
Non-covered services and the ABN
Denials under these LCDs are reasonable-and-necessary denials under §1862(a)(1)(A). The patient can be held liable only if a valid ABN (Form CMS-R-131) was signed before the service.
Signed ABN on file
Expected denial as not reasonable and necessary. Patient accepted financial responsibility before the service.
No ABN
Expected denial, no ABN signed. The practice absorbs the cost and cannot bill the patient.
Voluntary notice
For statutory or technical denials only. Not the modifier for an LCD medical-necessity denial.
Statutory exclusion
No Medicare benefit category. Rarely the right choice for nerve procedures.
Proposed (Sept 2025) versus final (Sept–Oct 2026)
The proposal covered only trigeminal RF neurolysis and steroid injections for carpal tunnel and Morton's neuroma. Specialty societies, physicians and patients submitted comments; the MACs added limited coverage where they judged the evidence sufficient.
| Target | Proposed | Final |
|---|
Where the final LCDs still fall short
The MACs point to the LCD reconsideration process, which requires new published evidence. Clinicians who publish or run registries in these areas can help close these gaps.
- Therapeutic blocks of other peripheral nerves (64450) and their destruction (64640) are non-covered.
- Genicular work requires KL grade 3–4; KL 2 patients are excluded.
- Ablation requires the patient be a poor surgical candidate or decline surgery.
- Genicular ablation after total knee arthroplasty is non-covered beyond the perioperative period.
- Therapeutic genicular injections are deemed insufficiently supported.
- Cryotreatment near −88 °C is not covered outside the perioperative setting.
- Occipital and suprascapular RFA remain investigational.
- Therapeutic pudendal, ganglion impar, intercostal and ESP blocks remain non-covered.
- Coverage now differs across MACs: Novitas and First Coast did not adopt this LCD.