Is medical necessity met for a bilateral erector spinae thoracic block (procedure code 64999) for pain management in a patient with multiple rib fractures?

Medical Necessity Determination for Bilateral Erector Spinae Plane Block (CPT 64999)

Direct Answer

Medical necessity is NOT met for bilateral erector spinae plane (ESP) block (CPT 64999) in this 63-year-old male with multiple rib fractures on 03/10/2025, as the payer's clinical policy bulletin explicitly classifies ESP blocks for pain control in multiple rib fractures as experimental and investigational.

Analysis Framework

Payer Policy Takes Precedence

The Aetna Clinical Policy Bulletin 0863 specifically lists erector spinae plane blocks for "pain control in multiple rib fractures" as experimental and investigational because "the effectiveness of these approaches has not been established." This policy determination supersedes clinical evidence when making coverage determinations, as payer policies define the contractual boundaries of medical necessity for reimbursement purposes.

Clinical Context vs. Coverage Policy Conflict

While emerging research demonstrates potential clinical benefit of ESP blocks for rib fracture pain management, this creates a disconnect between clinical utility and coverage policy:

Clinical Evidence Supporting ESP Blocks:

• ESP blocks significantly reduce pain scores (mean reduction from 7.93 to 4.47, p<0.001) and improve incentive spirometry volumes (1160cc to 1495cc, p=0.035) in rib fracture patients 1
• ESP blocks provide comparable analgesia to thoracic epidural with better hemodynamic stability (MAP 64.8±2.1 vs 57.2±1.3 mmHg, p<0.00001) 2
• ESP blocks demonstrate equivalent efficacy to thoracic paravertebral blocks with lower adverse effect incidence 3
• Case reports document successful use as primary analgesic technique for extensive rib fractures (4th-11th ribs) 4

However, the evidence base remains limited:

• Studies are small (n=45 1, n=40 2, n=60 3)
• No large randomized controlled trials establish superiority over standard multimodal analgesia
• Most evidence is from 2022-2023, representing emerging rather than established practice 1, 2, 3

Alternative Pain Management Approaches

The clinical guidelines emphasize multimodal analgesia as the established standard for rib fracture pain management 5. Established, covered alternatives include:

• Non-opioid analgesics as first-line therapy 5
• Opioid analgesics for severe pain based on fracture displacement and number 5
• Thoracic epidural analgesia (established technique with strong evidence) 2
• Intercostal nerve blocks (traditional regional technique)

Surgical Stabilization Context

The patient declined surgical stabilization of rib fractures (SSRF). While this is relevant to overall management, the guidelines indicate:

• SSRF should be performed within 48-72 hours for optimal outcomes 6
• The patient was on day 2 post-injury (03/08 to 03/10), still within the early intervention window 6
• Patient refusal of SSRF does not automatically justify experimental nerve block techniques for coverage purposes

Clinical Severity Assessment

The patient's clinical picture includes:

• Multiple rib fractures (S22.49XA, S22.32XA)
• Traumatic hemopneumothorax requiring chest tube placement (S27.2XXA)
• Worsening subcutaneous emphysema
• 63 years old (not elderly by guideline standards, which focus on ≥65 years) 6

This represents significant thoracic trauma warranting aggressive pain management, but the payer policy does not make exceptions based on severity for procedures classified as experimental.

Coverage Determination

The bilateral ESP block does not meet medical necessity criteria under the applicable coverage policy. The procedure is explicitly excluded as experimental/investigational regardless of:

• Clinical appropriateness
• Severity of injury
• Patient tolerance of the procedure
• Emerging evidence of efficacy

Critical Pitfalls

• Do not confuse clinical appropriateness with coverage determination - a procedure can be clinically reasonable yet not meet payer-defined medical necessity 1, 2, 3
• Emerging evidence does not override explicit policy exclusions - the 2022-2023 research supporting ESP blocks has not yet translated into coverage policy changes
• The "unlisted procedure" code (64999) does not circumvent policy - payers evaluate the actual procedure performed, not the billing code used

Recommendation for Provider

Appeal options are limited but include:

• Documenting failure of all covered alternative pain management modalities
• Requesting peer-to-peer review to discuss clinical necessity despite policy exclusion
• Submitting case as exception request with documentation of clinical deterioration and contraindications to covered alternatives (e.g., coagulopathy precluding epidural) 4

For future similar cases:

• Verify coverage policy before performing procedures with emerging evidence bases
• Consider thoracic epidural as first-line regional technique when not contraindicated 2
• Document medical necessity for any deviation from standard multimodal analgesia protocols 5