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The 1 in 5 Americans suffering from chronic pain may soon lose access to evidence-based interventions that have existed for decades. Looming changes to Medicare coverage threaten access to local anesthetic blockade, or “peripheral nerve block” procedures. Medicare administrative contractors across the country have recently proposed eliminating coverage for these minimally invasive, non-opioid treatment options for chronic pain disorders. If approved, these coverage changes could drive patients back to opioids, exacerbating the overdose epidemic in the United States, and force patients to unnecessarily pursue invasive and expensive surgical interventions. Advertisement Chronic pain is a leading cause of disability in the United States. It is associated with depression, substance use disorders, an economic burden of $722.8 billion in medical costs annually, and lost productivity. Chronic pain diagnoses are more prevalent in veterans, women, adults living in poverty, and those residing in rural areas. The challenge of balancing the treatment of chronic pain with addressing the opioid overdose epidemic remains one of the preeminent public health challenges in the United States. Guidelines issued by the American Society of Anesthesiologists’ Task Force on Chronic Pain Management emphasize the importance of a multimodal approach to therapy including non-opioid pain medications, physical and psychological therapy, and minimally invasive procedures. Peripheral nerve blocks are minimally invasive procedures that are well-tolerated by patients. They are considered relatively low-cost interventions, especially when compared with alternatives such as orthopedic surgery under general anesthesia or hospital admissions for severe pain requiring treatment with intravenous opioid medications. These interventions have broad applications for patients living with conditions that cause chronic pain, such as headache disorders and trigeminal neuralgia. Trigeminal neuralgia is a condition characterized by unpredictable attacks of facial pain that are so severe the condition is associated with depression and suicidal ideation. These patients frequently report immediate pain relief after a peripheral nerve block, with the majority of patients experiencing a greater than 50% reduction in their pain, which can last several months and allow patients to return to work and childcare responsibilities. Advertisement Similarly, peripheral nerve blocks have demonstrated efficacy in both reducing pain during acute migraine attacks as well as preventing chronic migraines. Migraine patients who undergo occipital nerve blocks experience fewer headache days per month, which may lead to reduced consumption of pain medications (including opioids) and reduced migraine-associated disability. These procedures are also utilized for patients struggling with chronic pelvic pain, adhesive capsulitis (frozen shoulder), knee osteoarthritis, and complex regional pain syndrome. If patients experience pain relief from a peripheral block, some undergo the placement of peripheral nerve stimulators or denervation procedures that reduce or eliminate the nerve’s ability to transmit pain signals, however diagnostic peripheral nerve blocks must precede these interventions. The symptom relief from these procedures can last from months to years. Yet on Sept. 25, five of 12 Medicare administrative contractors (MACs) in the U.S., representing 24 states, announced their intention to dramatically restrict Medicare coverage for peripheral nerve blocks. Medicare contractors are private insurers that process claims for Medicare Parts A and B. Acting as intermediaries between the federal government and Americans insured by Medicare, these private entities make over 90% of coverage decisions in the United States by issuing Local Coverage Determinations (LCDs). These policies define which procedures and medications are “reasonable and necessary” for Medicare coverage and influence other government payers and commercial insurance programs. While this change would only affect the 24 states governed by the five MACs initially, other states could follow suit, and private insurers often follow too. Under the proposed LCDs, chronic pain procedures would be limited to three steroid injections for median nerve pain, two steroid injections for Morton’s neuroma, and radiofrequency neurolysis for trigeminal neuralgia. All other peripheral nerve blocks and denervation procedures would not be covered. Unless the MACs want more Americans to be unable to work, reliant on opioids, and suffering in pain, it’s hard to understand their motivation here. Eliminating peripheral nerve block coverage will not result in meaningful cost savings from these patients, and may lead to more frequent emergency department and clinic visits, increased use of opioids and other pharmacologic interventions, or more time spent on disability, ultimately raising direct and indirect health care expenditures in the United States. Advertisement These coverage changes have been met with concern from numerous professional groups including the American Society of Regional Anesthesia and Pain Medicine and the American Society of Interventional Pain Physicians, who criticized the LCDs’ extremely restrictive criteria to evaluate the efficacy of peripheral nerve blocks. Medicare administrative contractor websites state that the new policy was developed to “incorporate new procedures and literature.” However, the LCDs exceed the standards for evidence used in even Cochrane reviews, which are known to reject greater than 90% of available treatments. The analysis also ignores the ethical challenges of conducting randomized controlled trials, especially for procedures with decades of clinical use and established benefits. Additionally, the policies include procedures that do not fit the definition of peripheral nerve blocks, stellate ganglion and cervical sympathetic nerve blocks, as well as three irrelevant diagnostic procedure codes, which raises questions about the expertise of those writing the LCDs. Despite directives within the 21st Century Cures Act of 2016 calling for increased transparency throughout the LCD process, it is difficult to determine the people and associated conflicts of interests involved in the authorship of these documents. Only two of five MACs list a physician on the LCD’s website, and one of the two is an OB-GYN with no relevant advanced training. Physicians and advocates concerned about the proposed coverage changes should contact their state senate and house of representative healthy policy committees, register and provide expert opinions at contractor meetings, and share their clinical expertise during public comment periods open now until Nov. 8.
