Are nerve blocks 64417, 64418, and 64450 medically necessary for a 64-year-old male with chronic pain, lumbar post-laminectomy syndrome, cervical post-laminectomy syndrome, and peripheral neuropathy?

Medical Necessity Assessment for Proposed Nerve Blocks

Based on current evidence and payer criteria, only CPT 64450 (other peripheral nerve block) meets medical necessity criteria for this patient, while CPT 64417 (axillary nerve) and 64418 (suprascapular nerve) do not meet established indications for chronic shoulder pain. 1

Analysis by Procedure Code

CPT 64450 (Other Peripheral Nerve Block) - MEDICALLY NECESSARY

This procedure is appropriate as part of a comprehensive pain management program for this patient's complex chronic pain syndrome. 1

• Peripheral nerve blocks are considered medically necessary when used as part of an active comprehensive pain management program for chronic pain 1
• This patient demonstrates appropriate conservative treatment failure with ongoing multimodal therapy (tramadol, suzetrigine, norco, physical therapy, home exercise program) yet maintains pain scores of 6/10 with treatment and 10/10 without 1
• The patient has documented post-laminectomy syndrome affecting both cervical and lumbar regions, peripheral neuropathy, and has already undergone multiple interventional procedures (bilateral C3-6 facet blocks, femoral/obturator/lateral branch blocks) with a scheduled spinal cord stimulator trial, indicating appropriate escalation within a structured pain program 1, 2
• For post-laminectomy syndrome specifically, interventional techniques including peripheral nerve blocks are established therapeutic modalities when conservative management fails 2, 3

CPT 64417 (Axillary Nerve Block) - NOT MEDICALLY NECESSARY

Axillary nerve blocks lack established efficacy for chronic shoulder pain and are specifically listed as not meeting medical necessity criteria by major payers. 1

• Available guidelines explicitly state that axillary nerve blocks for chronic shoulder pain, shoulder bursitis, or post-operative pain control have not had their effectiveness established 1
• The clinical documentation lacks specific shoulder examination findings (noted as "no specific shoulder exam"), which is problematic when the primary indication would be shoulder-specific pathology 1
• Spurling test was negative and bilateral cervical facet loading was positive, suggesting the shoulder pain is more likely referred cervical pain rather than primary shoulder pathology requiring axillary nerve blockade 1
• Peripheral nerve blocks for upper extremity pain in cancer pain guidelines reference brachial plexus approaches, not isolated axillary nerve blocks for chronic non-malignant shoulder pain 1

CPT 64418 (Suprascapular Nerve Block) - NOT MEDICALLY NECESSARY

Suprascapular nerve blocks are not supported by evidence for the conditions present in this patient and are specifically excluded from coverage for chronic shoulder pain. 1

• Guidelines explicitly list suprascapular nerve blocks as having unestablished effectiveness for chronic upper extremity pain, cervical spondylosis, and adhesive capsulitis 1
• The patient's presentation suggests cervicogenic pain (positive bilateral cervical facet loading, recent bilateral C3-6 facet blocks on 10/27/25) rather than primary shoulder joint pathology that would respond to suprascapular blockade 1
• No documented shoulder-specific pathology (rotator cuff tear, adhesive capsulitis, glenohumeral arthritis) is present to justify this intervention 1

Critical Clinical Considerations

The positive bilateral cervical facet loading and recent cervical facet blocks suggest the shoulder pain is likely referred from cervical spine pathology rather than primary shoulder disease. 1

• Patients with cervical post-laminectomy syndrome commonly experience referred upper extremity pain that mimics shoulder pathology 2, 4
• The absence of specific shoulder examination findings and negative Spurling test further supports cervicogenic rather than primary shoulder pain 1
• Targeting the cervical source (already being addressed with facet blocks and planned SCS trial) is more appropriate than peripheral shoulder nerve blocks 1, 2

This patient is appropriately progressing through a structured interventional pain algorithm with planned spinal cord stimulator trial, which has established efficacy for post-laminectomy syndrome. 1, 5

• Spinal cord stimulation should be used for persistent radicular pain and post-laminectomy syndrome 1
• High-frequency SCS (10 kHz) has demonstrated effectiveness for post-laminectomy syndrome with concurrent pain from multiple sources 5
• The scheduled SCS trial represents appropriate escalation given failed conservative management and multiple prior interventional procedures 1, 5

Common Pitfalls to Avoid

Do not perform shoulder-specific nerve blocks based solely on patient-reported shoulder pain without documented shoulder-specific pathology and failed shoulder-specific conservative treatments. 1

• Referred pain from cervical spine pathology is extremely common in post-laminectomy patients and can masquerade as primary shoulder pain 2, 4
• Performing ineffective procedures delays appropriate treatment and increases costs without improving outcomes 3
• The lack of shoulder-specific examination findings in the documentation is a red flag that should prompt more thorough evaluation before proceeding 1

Ensure any peripheral nerve block (64450) targets an appropriate nerve distribution with documented pathology and is performed as part of ongoing comprehensive pain management, not as isolated treatment. 1

• The comprehensive pain program must include physical modalities, psychological support, and medication management, not just serial injections 1
• Document specific nerve targets and rationale for 64450 code to support medical necessity 1