If your practice treats carpal tunnel syndrome, knee osteoarthritis, or any other long-running pain condition with nerve injections, a new Medicare policy is about to change what gets paid. It takes effect in days, and plenty of scheduled appointments will fall under it.
This guide explains what the policy covers, which services lose coverage, which ones stay, and what your team should do this week.
Quick Answer: What Is the New Peripheral Nerve Injection LCD?
It’s a uniform local coverage determination (LCD) titled “Peripheral Nerve Injections and Procedures for Chronic Pain.” Five Medicare administrative contractors (MACs) issued it together. It limits Medicare coverage of many nerve injection and nerve destruction procedures when they’re used to treat chronic, non-cancer pain. It applies to 25 procedure codes and 43 diagnosis codes, and it takes effect October 25, 2026 for most participating MACs (November 1 for Noridian).
Who Issued It and Where It Applies
The five MACs behind the policy are CGS Administrators, Palmetto GBA, Noridian, Wellpoint Federal (formerly National Government Services), and WPS. Together they cover 38 states and three territories.
Two contractors stayed out of it. First Coast Service Options and Novitas did not take part in writing this LCD, so practices in their jurisdictions aren’t covered by this particular policy.
Effective Dates
| MAC | Effective date |
|---|---|
| CGS Administrators | October 25, 2026 |
| Palmetto GBA | October 25, 2026 |
| Wellpoint Federal | October 25, 2026 |
| WPS | October 25, 2026 |
| Noridian | November 1, 2026 |
The rule applies to services performed on or after the effective date. That matters because it covers appointments booked long before the final policy was published. A patient scheduled weeks ago is still affected if the visit lands after the start date.
What the LCD Does Not Change
The policy only addresses chronic pain that isn’t caused by cancer. Several areas sit outside its reach:
- Blocks used for acute pain
- Regional anesthesia
- Pain related to surgery
- Refractory cancer pain
- Joint impingement syndromes
- Neurotomies
- One-time diagnostic blocks used to identify a condition, unless the LCD says otherwise (pudendal nerve blocks, CPT 64430, are an example)
Even for unaffected services, expect closer scrutiny. Accurate diagnosis documentation and coding will be your best defense against denials, and your billing team should watch remittance advice codes closely once the policy is live.
Services That Will No Longer Be Covered for Chronic Pain
The MACs originally proposed much deeper cuts. The final version is softer, but it still removes coverage for several common services:
| Service | CPT code(s) |
|---|---|
| Peripheral nerve block (chronic pain) | 64450 |
| Peripheral nerve destruction (chronic pain) | 64640 |
| Intercostal nerve block | 64420 and add-on 64421 |
| Percutaneous cryoablation | 0440T-0442T |
If you’re deciding where to begin patient outreach, start with anyone booked for 64450 or 64640, since those are the services that stop being covered for chronic pain.
Codes Covered Only in Specific Circumstances
A few codes remain payable, but only when the LCD’s conditions are met:
- 64430: pudendal nerve injection
- 64999: unlisted nervous system procedure
- 64632: plantar nerve destruction
“Covered in specific circumstances” means the clinical situation has to match the LCD’s wording. Don’t assume a code is safe just because it isn’t on the non-covered list.
Example: Carpal Tunnel Syndrome Injections
The LCD allows median nerve injections for carpal tunnel syndrome when the patient has clinical symptoms and physical exam findings that fit the condition. When treatment meets those conditions, providers can report CPT 20526 (therapeutic carpal tunnel injection) with a CTS diagnosis in the G56.01-G56.03 range.
The takeaway is that the exam findings need to be in the chart. A diagnosis code alone won’t carry the claim.
Frequency Limits Start Fresh
Frequency limits begin on the effective date and don’t reach backward. Morton’s neuroma shows how this works. The policy allows one steroid injection per side. The MAC decides on a case-by-case basis whether repeat injections are medically necessary. If a patient had one or more injections before the LCD took effect, those earlier treatments don’t count toward that limit.
Provider Qualification Requirements
The LCD includes a provider qualification section. Physicians and other qualified healthcare professionals who perform these procedures must be able to show certified, accredited training, consistent with Medicare’s Program Integrity Manual. Acceptable routes include a formal residency or fellowship, certification from a recognized national organization, or an accredited post-graduate course.
At a minimum, training should build understanding of anatomy, drug pharmacology, diagnosis and disease management, technical performance of the procedure, and the imaging used alongside it.
You don’t need to attach diplomas or certificates to claims. You do need to keep proof of training on file in case a MAC runs a spot check.
Your Pre-Effective-Date Checklist
- Read the LCD, the companion billing and coding article, and the response to comments. Links to all three are in the LCD itself.
- Pull the schedule. Identify patients booked on or after the effective date for affected codes, especially 64450 and 64640.
- Check each patient against the coverage and limitation sections. Match diagnoses and exam findings to what the policy allows.
- Send advance notice of non-coverage when needed, and do it in time for the patient to make a decision.
- Train front-desk, clinical, and billing staff on what changed and why.
- Confirm provider training records are current and easy to find.
- Set up denial monitoring for remittance advice after go-live.
- Subscribe to MAC updates. Corrections are likely.
Watch for Corrections
MACs sometimes fix errors after publication. One example is already visible: the final LCD removed a lifetime limit on median nerve blocks but didn’t add a frequency limit in its place, which looks like an oversight. Updates may follow, so sign up for notices from your MAC.
Frequently Asked Questions
When does the peripheral nerve injection LCD take effect?
October 25, 2026 for CGS Administrators, Palmetto GBA, Wellpoint Federal, and WPS. Noridian’s version starts November 1, 2026.
Which CPT codes lose coverage for chronic pain?
64450 (peripheral nerve block), 64640 (peripheral nerve destruction), 64420 and 64421 (intercostal nerve blocks), and 0440T-0442T (percutaneous cryoablation).
Does this LCD apply to cancer pain or acute pain?
No. It addresses chronic, non-cancer pain only. Acute pain, surgical pain, regional anesthesia, and refractory cancer pain are outside its scope.
Which MACs are not part of this LCD?
First Coast Service Options and Novitas did not participate.
Can I still bill CPT 20526 for carpal tunnel injections?
Yes, when treatment meets the LCD’s conditions and the patient has a CTS diagnosis (G56.01-G56.03) with supporting symptoms and exam findings.
Do earlier injections count toward the new frequency limits?
No. Limits start on the effective date and aren’t applied retroactively.
Do providers have to submit training certificates with claims?
No, but they must keep proof of qualified training available for MAC spot checks.
Final Thoughts
With the effective date this close, the practical move is to audit your schedule now. Find the patients who are affected, document the clinical findings the LCD asks for, and make sure your team knows when advance notice is required. Then confirm the details against the LCD text and your own MAC’s guidance, since wording and corrections can change what applies to your claims.
Disclaimer: This article is for educational purposes only and isn’t a substitute for the official LCD, the companion billing and coding article, or guidance from your MAC. Always confirm coverage criteria with the current published documents. CPT® is a registered trademark of the American Medical Association.
