Medicare Releases Proposed LCD on Peripheral Nerve Blocks and Procedures for Chronic Pain With Elimination of Almost All Peripheral Nerve Blocks From Coverage Policy

I am Dr. Ajith Nair M.D., a board-certified physician in both Anesthesiology and Interventional Pain Medicine and Addiction Medicine and I currently maintain five total board certifications, including those from: – The American Board of Anesthesiology (with Added Qualifications in Pain Medicine) – The American Board of Interventional Pain Physicians For over 30 years, I have practiced exclusively in the field of interventional chronic pain medicine as the founder and medical director of Kentuckiana Pain Specialists, Louisville, KY, and owner of KPS Ambulatory Surgery Center, Louisville, KY My practice provides comprehensive pain management for patients across Kentucky—ranging from retirees and laborers to professionals and executives—always guided by evidence-based, minimally invasive principles. 1. Strong Opposition to Proposed LCD DL40300 The proposed LCD would eliminate Medicare coverage for nearly all peripheral nerve blocks and denervation procedures, except for a narrow subset (radiofrequency neurolysis for trigeminal neuralgia and corticosteroid injections for median neuropathy and Morton’s neuroma). This sweeping restriction is scientifically indefensible and clinically harmful. It disregards both the medical literature and decades of accepted interventional pain practice. 2. Established Evidence and Standard of Care Peripheral nerve blocks—including occipital, suprascapular, genicular, stellate ganglion, pudendal, thoracic sympathetic, and digital nerve blocks—are textbook-standard procedures. They are part of every ACGME-accredited anesthesiology and pain medicine training program and have been documented for decades in peer-reviewed studies and major reference texts. These interventions are neither experimental nor obsolete—they are essential tools in the continuum of care for patients with complex chronic pain. 3. Real-World Patient Impact Over three decades in practice, I have personally treated thousands of patients whose lives were measurably changed by peripheral nerve interventions. These are not anecdotal rarities; they represent consistent, reproducible clinical outcomes observed across virtually every peripheral distribution. For example, I routinely treat patients with: – Occipital neuralgia and cervicogenic headache, where greater and lesser occipital nerve blocks restore the ability to work, drive, and sleep after years of intractable pain. – Genicular nerve pain following total knee replacement, where diagnostic and therapeutic blocks yield sustained improvements in ambulation and independence when other therapies have failed. – Pudendal neuralgia and chronic pelvic pain, where periodic image-guided nerve blocks allow patients to perform basic life functions such as sitting, urination, and sexual activity without debilitating pain. – Suprascapular and axillary neuropathies, posterior tibial neuropathies, and post-thoracotomy neuralgias, each of which respond predictably to targeted peripheral nerve blocks or neurolysis. ALL the above are a small fraction of actual example cases of patients that depend on these peripheral blocks, where nothing else helps! These cases are representative of, thousands—of similar patients in my own practice, not to mention multiples of that nationwide in those of my colleagues’ practices. The proposed LCD would strip these individuals of treatments that are low cost, low risk, and medically indispensable, leaving only more invasive, expensive, or ineffective alternatives. 4. Scientific and Policy Concerns – The LCD lacks transparent, evidence-based rationale for the exclusion of these procedures. – The proposed injection limits (e.g., two or three in a lifetime, or annual limits) are arbitrary, with no clinical or outcomes-based justification. – The exclusions conflict with national educational standards, the Accreditation Council for Graduate Medical Education (ACGME) pain-medicine curriculum, and ASRA/ASIPP clinical guidelines. 5. Ethical and Economic Consequences Peripheral nerve blocks are among the most cost-effective, low-risk procedures available for chronic pain. They reduce opioid utilization, preserve function, and often prevent the need for expensive implantable devices or surgeries. Denying coverage will paradoxically increase overall Medicare spending while worsening quality of life for countless beneficiaries. 6. Requested Action I respectfully urge WPS Medicare to: 1. Withdraw the proposed LCD DL40300 in its entirety pending a comprehensive review with multidisciplinary expert input; or 2. Substantially revise the LCD to: – Allow up to two diagnostic peripheral nerve blocks, followed (if ≥ 50% relief is achieved) by up to at least three (3) therapeutic and/or 2 radiofrequency neurotomy procedures per year; (This is based off of CMS compliance guidelines of other neural/nerve “block”/ ablative therapy). 7. Closing I recognize the difficult balance between fiscal oversight and clinical necessity. However, this proposed LCD—if enacted—would dismantle an essential component of interventional pain medicine, contradict established science, and irreparably harm patient care. Thank you for your time, your consideration, and your commitment to maintaining thoughtful, evidence-based coverage for our patients. Respectfully submitted, Ajith Nair M.D. Board-Certified in Anesthesiology, Interventional Pain Medicine, Addiction Medicine President and CEO Kentuckiana Pain Specialists and KPS Ambulatory Surgery Center 3710 Chamberlain lane Louisville, KY 40241

PLEASE SEE BELOW FOR ALL LCD EMAIL ADDRESSES, A SAMPLE LETTER, AND SAMPLE SUBJECT. Subject: Public Comment for Proposed LCD – Peripheral Nerve Blocks and Procedures for Chronic Pain (DL40261) [email protected] [email protected] [email protected] [email protected] [email protected] [Date] To Whom It May Concern, My name is [YOUR NAME HERE], and I am an interventional pain management specialist practicing at [YOUR LOCATION AND OFFICE]. I am writing to respectfully express my concerns regarding the proposed Local Coverage Determination (LCD) policies related to nerve block procedures. Nerve blocks are a critical component of the treatment algorithm for patients suffering from chronic pain. These procedures are not only essential for effective pain management but are also central to opioid stewardship and the broader goal of preventing avoidable opioid addiction. By providing targeted pain relief, nerve blocks allow many patients to reduce or eliminate their reliance on opioid medications, thereby supporting responsible pain medicine practices and public health objectives. I am concerned that overly restrictive coverage policies may inadvertently limit access to these vital interventions. To ensure that patients receive the most appropriate and effective care, I respectfully recommend the following modifications to the current LCD: – Allow coverage for two diagnostic nerve blocks followed by up to two radiofrequency neurotomy procedures per year, or alternatively, up to four therapeutic nerve blocks annually. – Require that patients demonstrate at least 50% improvement in pain or function following both the first and second diagnostic blocks before proceeding to further interventions. These recommendations are consistent with evidence-based practice and would help ensure that only those patients who benefit from nerve blocks continue to receive them, while also supporting the goals of opioid reduction and responsible pain management. Thank you for your time and consideration of these important issues. I am available to discuss these recommendations further and am committed to working collaboratively to ensure the best outcomes for our patients. Sincerely, [Your Office Here]