Is a superficial cervical plexus block (CPT 64999) medically indicated for post-operative pain management after shoulder surgery for a patient with a diagnosis of other acute postprocedural pain (G89.18)?

Medical Necessity Determination: Superficial Cervical Plexus Block for Post-Operative Shoulder Pain

The superficial cervical plexus block (CPT 64999) performed on 8/13/2025 for post-operative pain management after rotator cuff repair is NOT medically indicated and does not meet medical necessity criteria.

Evidence-Based Rationale

Guideline-Directed Regional Anesthesia for Shoulder Surgery

The 2019 PROSPECT guidelines—the most authoritative procedure-specific pain management recommendations for rotator cuff repair—explicitly identify interscalene brachial plexus block as the first-choice regional analgesic technique for shoulder surgery 1. The guidelines make no mention of superficial cervical plexus block as a recommended intervention for shoulder procedures 1.

The recommended analgesic regimen for rotator cuff repair includes:

• Interscalene brachial plexus block (continuous or single-shot) as first-line regional technique 1
• Suprascapular nerve block with or without axillary nerve block as an alternative when interscalene block is contraindicated 1
• Systemic analgesia with paracetamol and NSAIDs 1
• IV dexamethasone to prolong block duration 1
• Opioids reserved for rescue analgesia only 1

Specific Evidence Against Superficial Cervical Plexus Block for Shoulder Surgery

The Aetna Clinical Policy Bulletin explicitly states that cervical plexus block (superficial and deep) for management of post-operative pain after shoulder surgery is considered insufficient evidence (not medically necessary). This directly applies to the case at hand where CPT 64999 was used for superficial cervical plexus block following right shoulder rotator cuff repair.

The American Society of Anesthesiologists 2012 guidelines on acute pain management discuss peripheral nerve blocks but do not recommend cervical plexus blocks for shoulder surgery pain management 1. The evidence base focuses on interscalene blocks, suprascapular blocks, and other shoulder-specific regional techniques 1.

Anatomical and Clinical Considerations

Superficial cervical plexus block provides sensory innervation to:

• Skin of the neck 2
• Upper shoulder area (superficial structures only) 2
• Occipital scalp 2

This anatomical distribution does NOT adequately cover:

• The glenohumeral joint (primary pain source in rotator cuff repair)
• Deep shoulder structures
• The surgical field of arthroscopic rotator cuff repair

The superficial cervical plexus block has established utility for carotid endarterectomy and neck surgeries 2, and has been studied for preventing cervicocephalic pain after neurosurgery 3, but these indications are anatomically and procedurally distinct from shoulder surgery.

What Should Have Been Done

In this specific case, the patient received:

• Interscalene brachial plexus block (CPT 64415) - APPROPRIATE and medically necessary 1, 4
• Superficial cervical plexus block (CPT 64999) - NOT medically necessary

The interscalene block alone provides comprehensive analgesia for shoulder surgery and is the evidence-based standard of care 1, 4, 5. Adding a superficial cervical plexus block provides no additional benefit for shoulder pain management and represents an unnecessary procedure without supporting evidence 1.

Alternative Regional Techniques with Evidence

If interscalene block were contraindicated or inadequate, the evidence-based alternatives would be:

• Suprascapular nerve block with or without axillary nerve block 1, 4
• Combined suprascapular and infraclavicular blocks (emerging evidence) 6

NOT superficial cervical plexus block 1.

Clinical Pitfalls and Caveats

Common error: Assuming that blocking additional nerves in the cervical region will enhance analgesia for shoulder surgery. The superficial cervical plexus does not innervate the deep shoulder structures involved in rotator cuff repair 2.

Billing consideration: CPT 64999 is an unlisted code requiring specific justification. When used for a procedure lacking evidence-based support (superficial cervical plexus block for shoulder surgery), it fails medical necessity criteria regardless of technical execution.

Documentation issue: While the procedure note describes technically appropriate performance of the block, technical competence does not establish medical necessity when the intervention itself lacks evidence-based indication for the specific clinical scenario.

Final Determination

CPT 64999 (superficial cervical plexus block) performed on 8/13/2025 for diagnosis G89.18 (acute postprocedural pain) following right shoulder rotator cuff repair does NOT meet medical necessity criteria. The procedure is explicitly listed as insufficient evidence for post-operative pain management after shoulder surgery in the Aetna CPB, is not recommended by PROSPECT guidelines for rotator cuff repair 1, and provides no anatomical coverage of the surgical site or deep shoulder structures 2. The interscalene block (CPT 64415) performed concurrently was the appropriate and evidence-based intervention 1, 4.