Medical Necessity Determination for Intercostal Nerve Blocks
Recommendation
The intercostal nerve blocks (CPT 64420,64421) performed on 12/26/2024 for this patient with Chondrocostal Junction Syndrome (Tietze syndrome), chronic pain, and thoracic muscle spasms are medically necessary and should be certified, consistent with the previous authorization for the same patient.
Clinical Context and Rationale
This 26-year-old female has documented:
- Thoracic paraspinal muscle spasms and rib arthritis with pain rated 7/10 affecting daily activities 1
- Reproducible 2-3 month pain relief from previous intercostal blocks performed on 6/27/2024 and 8/30/2024 (previously certified under MR# 8517477) 1
- Failed conservative management including chiropractic care, massage, NSAIDs, and dry needling 1
- Imaging confirmation of thoracic spine abnormalities (minimal dextroscoliosis on 7/5/2024) 1
Guideline-Based Analysis
Aetna CPB 0863 Criteria Assessment
The Aetna policy states intercostal nerve blocks are medically necessary for:
- Acute intercostal pain
- Chronic intercostal neuritis as part of a comprehensive pain management program 1
This patient meets criteria because:
Comprehensive pain management program is documented: The patient is receiving multimodal therapy including anti-inflammatory medications, heat therapy, dry needling, and interventional procedures 1, 2
Chronic intercostal pain is present: The operative report documents "thoracic paraspinal muscle spasms/arthritis of the rib areas" with injections performed at T11-T12 rib areas where primary pain complaints are localized 1
Not sole treatment: The American Society of Anesthesiologists guidelines specify that peripheral nerve blocks should only be used as part of a comprehensive pain management program, not as sole treatment 2. This patient's care clearly demonstrates multimodal management 1
Key Distinguishing Factors
Why This is NOT "Insufficient Evidence"
The Aetna policy lists intercostal blocks for "sole treatment of chronic intercostal neuritis" as insufficient evidence. This patient does not fall into that exclusion because:
- She is receiving concurrent therapies (NSAIDs, physical modalities, dry needling) 1
- The blocks provide documented temporary relief (2-3 months), requiring repeat intervention as part of ongoing management 1
- This represents active comprehensive pain management, not sole reliance on nerve blocks 2
Consistency with Previous Authorization
Critical consideration: The identical procedure was previously certified for this patient (MR# 8517477) on 6/27/2024 and 8/30/2024 with diagnoses including:
- M94.0 (Chondrocostal Junction Syndrome - same as current)
- Multiple arthritis diagnoses
- M54.2 (Cervicalgia)
The current presentation on 12/26/2024 includes:
- M94.0 (Chondrocostal Junction Syndrome - same)
- R07.9 (Chest pain)
- G89.29 (Chronic pain)
- M62.830 (Muscle spasm of back)
The clinical scenario is identical or improved (pain rated 4/10 pre-procedure on 12/26/2024 versus 6-7/10 previously), with documented efficacy from prior blocks 1. Denying this procedure would be inconsistent with prior authorization and contradict the documented treatment response 1.
Evidence Quality Assessment
Supporting Evidence:
- ASA/ASRA Practice Guidelines (2010): Nerve blocks may be used for chronic pain as part of comprehensive management 1
- Documented therapeutic response: 2-3 months relief with previous blocks establishes efficacy for this individual patient 1
- Praxis Medical Insights: Confirms ASA recommendations that peripheral nerve blocks should be part of comprehensive pain management programs 2
Addressing Experimental Designation:
This is NOT experimental. The procedure is:
- Recognized in established CPT codes (64420,64421) 1
- Included in Aetna's medical necessity criteria (CPB 0863) 1
- Supported by ASA/ASRA practice guidelines for chronic pain management 1
- Previously authorized for this identical patient and indication 1
Common Pitfalls Avoided
Misapplication of "sole treatment" exclusion: The patient is receiving multimodal therapy, not nerve blocks alone 1, 2
Ignoring documented efficacy: Previous blocks provided 2-3 months relief, establishing individual patient response 1
Inconsistent application: Denying after previous certification for identical indication would be arbitrary 1
Diagnosis code focus: While M94.0 (Tietze syndrome) is not specifically listed in CPB 0863, the clinical presentation is "thoracic paraspinal muscle spasms/arthritis of rib areas" causing intercostal pain, which is covered 1
Clinical Caveats
- Frequency monitoring: With 2-3 month relief intervals, approximately 4-6 procedures annually would be reasonable 1
- Ongoing comprehensive management: Continued multimodal therapy must be documented 2
- Functional outcomes: Document improvement in daily activities, not just pain scores 1
- Alternative considerations: If efficacy diminishes, consider radiofrequency ablation or other interventions 1
Final Determination
CERTIFY as Medically Necessary 1, 2
This procedure meets Aetna CPB 0863 criteria for intercostal nerve blocks as part of comprehensive chronic pain management, demonstrates documented efficacy in this patient, and is consistent with previous authorization. The procedure is not experimental and represents appropriate evidence-based care 1, 2.