Voices in Pain Medicine: Preserving Access to Peripheral Nerve Blocks for Chronic Pain: Two Resident Physicians’ Perspectives on Medicare’s Proposed Local Coverage Determination (LCD)

Why This Issue Matters Now

Chronic pain affects nearly a quarter of U.S. adults and is a leading cause of disability among Medicare beneficiaries. This population includes older adults, individuals with disabilities, and those with complex comorbidities. For these vulnerable patients, policy changes can have profound and far-reaching consequences. As resident physicians in physical medicine and rehabilitation (PM&R), we are not only learning from today’s expert physicians in pain management, but also preparing to care for the next generation of patients living with chronic pain. In our training, we both cared for similar patients in our respective pain clinics: two patient examples of women in their 50s particularly stand out. These patients were burdened by years of daily, debilitating migraines. Their pain had forced them to limit their work schedules and withdraw from their communities. They had exhausted every option, including preventive medications, triptans, physical therapy, even Botox injections. Nothing brought lasting relief.

When they finally received an occipital nerve block, the results were immediate and significant. Their pain intensity dropped dramatically, and the daily pounding headaches that dominated their lives became occasional and manageable. Within weeks, they were back at work and reengaging in life. They were not cured, but regained a sense of independence, hopefulness, and self.

Stories like these are not rare. Many Medicare beneficiaries, whether older adults or those on disability, face similar struggles. We have seen firsthand that peripheral nerve blocks are not experimental or foreign, but life-changing. Peripheral nerve blocks and related procedures are essential components of evidence-based, multidisciplinary pain management by offering targeted relief, reduced reliance on systemic medications, including opioids, and improved function and quality of life. These procedures are often the difference between isolation and participation, dependence, and autonomy.

The policies we shape now will define the future of pain management for years to come. That is why the recently proposed Medicare Local Coverage Determination policy (LCD DL40265) is so concerning. This proposal threatens access to peripheral nerve interventions like occipital, suprascapular, and genicular nerve blocks. Such treatments have robust clinical support that provided patients targeted relief, improved function, and reduced reliance on opioids. If implemented, this policy would significantly restrict coverage, directly threatening patient care and forcing patients back toward riskier, less effective, or more invasive options. Especially as our population ages and the demand for safe, cost-effective pain management grows, the stakes could not be higher.

Background: The Proposed LCD and Its Implications

The proposed LCD (see pages 1-5 of the policy document) aims to update coverage for peripheral nerve blocks and procedures for chronic pain, replacing previous policies. However, it introduces sweeping non-coverage for many commonly performed blocks and ablations, including occipital, suprascapular, genicular, pudendal, and digital nerve blocks, as well as radiofrequency ablation (RFA) and cryoneurolysis for most chronic pain indications, except for a narrow set of diagnoses (e.g., trigeminal neuralgia, carpal tunnel syndrome, Morton’s neuroma).

This is not just a bureaucratic change. It’s a direct threat to patient care, clinical best practices, and the future of pain medicine.

Clinical Significance: Evidence and Patient Impact

Peripheral nerve blocks are not experimental or fringe therapies. They are supported by a robust body of research, including randomized controlled trials, meta-analyses, and national guidelines.

Take for example, genicular nerve blocks and ablation for knee osteoarthritis. Multiple high-quality studies have validated these procedures, confirming that they provide meaningful pain relief and improved function, especially for patients who cannot undergo surgery [1-8, 10]. The American Society of Pain and Neuroscience recommends genicular RFA as a safe, effective, and cost-saving option [4, 7]. These procedures not only demonstrate strong efficacy but also reduce the need for opioids and hospitalizations, ultimately proving to be a cost-effective solution that meaningfully improves patients’ quality of life [21] while reducing the overall economic burden on the healthcare system

Similarly, occipital nerve blocks have also been shown in systematic reviews and randomized trials to be effective for migraine, cluster headache, cervicogenic headache, and occipital neuralgia, with rapid pain reduction and minimal side effects [11, 12, 17]. Often reserved as a last resort for patients who have failed oral medications, these interventions are supported by guidelines from the Department of Veterans Affairs and the American Academy of Neurology [17, 18].

For patients with chronic shoulder pain, suprascapular nerve blocks offer significant improvements in pain and function, often outperforming intra-articular steroid injections [13, 14]. These interventions are especially valuable for patients who are not surgical candidates due to age or comorbidities.

Pudendal nerve blocks, too, have a strong evidence base. Retrospective and systematic reviews support their use for pudendal neuralgia, showing meaningful short-term pain relief and improved daily function in patients who have not responded to conservative therapy [15, 16].

Beyond these examples, a growing body of evidence supports other peripheral nerve blocks and ablations, including those targeting thoracic, abdominal, and digital nerves. These interventions have also demonstrated efficacy in systematic reviews and clinical trials for chronic pain syndromes, with high rates of pain relief and low complication rates [9, 19, 20].

Taken together, this evidence underscores a crucial point: peripheral nerve blocks are essential components of modern pain management. Removing access to these evidence-based interventions strips clinicians of a vital tool in the toolbox and leaves patients with chronic, refractory pain fewer options for relief.

Why Coverage Matters: The Detrimental Impact of Non-Coverage

If Medicare eliminates or restricts coverage for these procedures:

Moreover, peripheral nerve blocks are opioid-sparing. Restricting access will likely increase opioid prescriptions, with all the attendant risks of dependence, overdose, and adverse events. These procedures are also cost-effective, reducing hospitalizations, emergency visits, and the need for more expensive interventions.

Equity and access are also at stake. Restricting coverage disproportionately harms those with limited resources, mobility, or access to specialty care, further exacerbating health disparities.

Call To Action: Alignment with AAPM’s Mission and Values and Advocacy

The mission of AAPM and the field of pain medicine is to advance patient care through education, advocacy, and interdisciplinary collaboration. The proposed LCD stands in direct opposition to these values, threatening access to evidence-based interventions that restore dignity, function, and quality of life for Medicare beneficiaries.

As resident physicians and future pain specialists, we are privileged to care for some of the most vulnerable members of our society, including older adults, individuals with disabilities, and those living with chronic pain. The Medicare population is rapidly aging, and the prevalence of chronic pain is only expected to rise. Restricting access to proven therapies like peripheral nerve blocks will disproportionately harm these populations who are already at risk of being marginalized by the healthcare system.

This policy risks deepening existing inequities. If coverage is denied, only those with the financial means will be able to pay out of pocket for these procedures, while others, often those with the greatest need, will be left to suffer. These policies may create a system where access to pain relief depends on where a patient lives or their ability to pay, rather than clinical need. From a healthcare spending perspective, limiting access to cost-effective, minimally invasive interventions is shortsighted. Without coverage for peripheral nerve blocks, patients may be forced to rely on more expensive, riskier treatments such as long-term opioid therapy, repeated hospitalizations, or invasive surgeries. This not only increases overall healthcare costs but also places additional strain on families, caregivers, and the broader social safety net.

Now is the time for bold, unified action. We must:

1. Engage in Advocacy: Submit comments to Medicare during the open comment period, and collaborate with specialty societies and patient advocacy groups to present a unified, evidence-based case for continued coverage.
2. Educate Stakeholders: Share real-world patient stories and outcomes, and highlight the robust clinical evidence and guideline support for peripheral nerve blocks and related procedures.
3. Promote Interdisciplinary Solutions: Advocate for policies that support comprehensive, multimodal pain management, not just pharmacologic or surgical approaches.
4. Advance Patient Selection and Outcomes: Support the development of clear, evidence-based criteria to identify patients who benefit most from these interventions, and encourage ongoing research and outcome tracking to ensure responsible, effective care.

We urge policymakers to consider the real-world impact of these decisions, not just on budgets, but on the daily lives of those we serve. As AAPM Resident Ambassadors, we are committed to mobilizing fellow resident ambassadors and trainees to raise awareness, submit comments to all Medicare Administrative Contractors (MACs), and advocate for our patients’ needs. Our collective voice is essential in shaping policies that will define the future of pain medicine.

We cannot forget the patients whose lives have been transformed by these procedures. Policies like the proposed LCD would take that opportunity away from thousands who depend on Medicare for access to evidence-based pain care. We call on Medicare to reconsider this proposal and preserve coverage for peripheral nerve blocks and related procedures. These interventions are not only clinically effective and cost-conscious, but essential for the dignity, function, and well-being of our most vulnerable patients. Upholding access to these procedures is fundamental to the mission of pain medicine and the future of compassionate, equitable care for all.

Eric Toan Phong Nguyen, DO
Resident Physician, PGY-2
Department of Physical Medicine and Rehabilitation
Charles R. Drew University of Medicine and Science

David Jevotovsky, MD, MBA
Resident Physician, PGY-4
Department of Physical Medicine and Rehabilitation
NYU Langone Health

References

1. Efficacy and Safety of Genicular Nerve Ablation Techniques for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Sham-Controlled Randomized Trials. Barreto RB, Barreto AJ, do Nascimento ALM, Carvalho DMB, Queiroz B. Pain Medicine (Malden, Mass.). 2025;:pnaf140. doi:10.1093/pm/pnaf140. New Research
2. Navigating Current Controversies in Radiofrequency Ablation of the Genicular Nerves for Chronic Knee Pain in Osteoarthritis: A Daring Discourse. Ferreira-Silva N, Ferreira-Dos-Santos G, Cuñat T, Ribeiro-da-Silva T, Peng P. Regional Anesthesia and Pain Medicine. 2025;:rapm-2025-106518. doi:10.1136/rapm-2025-106518. New Research
3. Genicular Nerve Block for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Vilchez-Cavazos F, Gamboa Alonso AA, Simental-Mendía M, et al. The Clinical Journal of Pain. 2024;40(10):618-624. doi:10.1097/AJP.0000000000001240.
4. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) From the American Society of Pain and Neuroscience. Hunter CW, Deer TR, Jones MR, et al. Journal of Pain Research. 2022;15:2683-2745. doi:10.2147/JPR.S370469.
5. Efficacy and Safety of Nerve Ablation Techniques Versus Sham Procedures in Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Antunes Júnior CR, de Oliveira Pinto RC, Barreto ESR, et al. Pain Practice : The Official Journal of World Institute of Pain. 2025;25(7):e70073. doi:10.1111/papr.70073.
6. The Analgesic Effectiveness of Genicular Nerve-Targeted Cooled and Pulsed Radiofrequency Ablation for Osteoarthritis Knee Pain: A Systematic Review and Meta-Analysis. Soetjahjo B, Adriansyah D, Yudistira MB, et al. Pain Physician. 2024;27(7):357-373.
7. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines From the American Society of Pain and Neuroscience (ASPN). Lee DW, Pritzlaff S, Jung MJ, et al. Journal of Pain Research. 2021;14:2807-2831. doi:10.2147/JPR.S325665.
8. A Prospective Randomized Trial of Prognostic Genicular Nerve Blocks to Determine the Predictive Value for the Outcome of Cooled Radiofrequency Ablation for Chronic Knee Pain Due to Osteoarthritis. McCormick ZL, Reddy R, Korn M, et al. Pain Medicine (Malden, Mass.). 2018;19(8):1628-1638. doi:10.1093/pm/pnx286.
9. Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias. Abd-Elsayed A, Anis A, Kaye AD. Current Pain and Headache Reports. 2018;22(1):5. doi:10.1007/s11916-018-0657-9.
10. Genicular Nerve Block for Pain Management in Patients With Knee Osteoarthritis: A Randomized Placebo-Controlled Trial. Shanahan EM, Robinson L, Lyne S, et al. Arthritis & Rheumatology (Hoboken, N.J.). 2023;75(2):201-209. doi:10.1002/art.42384.
11. Narrative Review of Peripheral Nerve Blocks for the Management of Headache. Stern JI, Chiang CC, Kissoon NR, Robertson CE. Headache. 2022;62(9):1077-1092. doi:10.1111/head.14385.
12. Efficacy and Safety of Greater Occipital Nerve Block for the Treatment of Cervicogenic Headache: A Systematic Review. Caponnetto V, Ornello R, Frattale I, et al. Expert Review of Neurotherapeutics. 2021;21(5):591-597. doi:10.1080/14737175.2021.1903320.
13. Suprascapular Nerve Blockage for Painful Shoulder Pathology – A Systematic Review and Meta-Analysis of Treatment Techniques. Batten TJ, Evans JP, Burden EG, et al. Annals of the Royal College of Surgeons of England. 2023;105(7):589-598. doi:10.1308/rcsann.2022.0026.
14. Intra-Articular Corticosteroid Injection Versus Suprascapular Nerve Block for Adhesive Capsulitis: A Systematic Review and Meta-Analysis of Level I Randomized Controlled Trials. Harley JD, Austin CN, Harrison AK, Saltzman BM, Rao AJ. Journal of Shoulder and Elbow Surgery. 2025;:S1058-2746(25)00513-0. doi:10.1016/j.jse.2025.05.037.
15. Fluoroscopy-Guided Transgluteal Pudendal Nerve Block for Pudendal Neuralgia: A Retrospective Case Series. Levin D, Van Florcke D, Schmitt M, et al. Journal of Clinical Medicine. 2024;13(9):2636. doi:10.3390/jcm13092636.
16. Impact of Treatment of Pudendal Neuralgia on Pain: A Systematic Review and Meta-Analysis. Andiman SE, Maron JS, Dandolu V, et al. International Urogynecology Journal. 2025;36(1):35-58. doi:10.1007/s00192-024-06004-x.
17. Management of Headache (2023). Jane Abanes PhD DNP MSN/Ed PMHCNS PMHNP-BC RN, Natasha M. Antonovich PharmD BCPS, Andrew C. Buelt DO, et al. Department of Veterans Affairs
18. Practice Parameter: The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia (An Evidence-Based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Gronseth G, Cruccu G, Alksne J, et al. Neurology. 2008;71(15):1183-90. doi:10.1212/01.wnl.0000326598.83183.04.
19. Radiofrequency Ablation’s Effectiveness for Treating Abdominal and Thoracic Chronic Pain Syndromes: A Systematic Review of the Current Literature. Vachirakorntong B, Kawana E, Zhitny VP, et al. Pain Physician. 2023;26(7):E737-E759.
20. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. Juch JNS, Maas ET, Ostelo RWJG, et al. JAMA. 2017;318(1):68-81. doi:10.1001/jama.2017.7918.
21. Desai, M., Bentley, A., Keck, W. A., Haag, T., Taylor, R. S., & Dakin, H. (2019). Cooled radiofrequency ablation of the genicular nerves for chronic pain due to osteoarthritis of the knee: a cost-effectiveness analysis based on trial data. BMC musculoskeletal disorders, 20(1), 302. https://doi.org/10.1186/s12891-019-2681-2