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11/10/2004    Michael J. Schneider, DPM

Controlled Studies for Neurolytic Injections

Query: Controlled Studies for Neurolytic

I have received a letter from the Sentinel
Group/ Trustmark in which they are requesting a
refund for payments made for CPT 64640. This was
for neurolytic injections for neuromas. The
injections are .5cc of 4% ethanol in
Marcaine .5%. This office has had excellent
results with this treatment. Trustmark states
that the lack of scientific evidence makes this
procedure “experimental/investigational for
research purposes." They consider it not
medically necessary.
They have the articles published by Dr. Dockery
and they state that his experiences do not
constitute controlled studies performed
consistent with scientific method. Does anyone
have knowledge of controlled clinical research

Michael J. Schneider, DPM
Vail, CO

Other messages in this thread:

11/12/2004    Multiple Respondents

Controlled Studies for Neurolytic Injections (M. Schneider, DPM)

RE: Controlled Studies for Neurolytic Injections
(M. Schneider, DPM)
From: Multiple Respondents

The APMA Coding Committee agrees that code 64640
is the correct code to bill for sclerosing
injections. However, this code was not
originally introduced into CPT with this
procedure in mind.

BMAD data for 64640, which APMA regularly tracks
and is posted on our members only website,
reveals a significant uptick in use of this
code. We also know that some carriers are
beginning to note this increase.

Lloyd S. Smith, DPM
President, American Podiatric Medical Association

I have a small reference book published by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and
Stroke, National Institutes of Health, U.S.
Department of HHS, Bethesda, MD 20892-2540,
(Publication # 04-3825, April 2004)

This lists nearly all public and private support
agencies for people who are interested in
neurological disorders, including their names
and telephone numbers. One can also obtain much
information like this on the Internet. A brief
listing of the agencies you intend to "inform"
about their insurance gaming refusal on alcohol
injections could be sent your patients' insurer.

Please contact me if you have any interest in
this. I am an expert on fighting insurance
company gaming.

Michael M. Rosenblatt, DPM
San Jose, CA

BCBS of Michigan began a new policy in Jan 2004
stating neurolysis occurs after ONE injection
and BCBS will only pay for the procedure ONE
time. BCBS-MI subsequently established their
own code to replace 64640 for neurolysis by
injection. In fact, BCBS has asked for return
payments for multiple 64640 codes used by our
office in the last 18 months! We are appealing
that request.

As I have written to BCBS in protest to the
above decision that I think the problem is the
fact that the insurance companies' fee schedule
is different for a particular injection given
the type of agent. Why should an injection of
4% alcohol pay vastly different (about $200 more
in our state) than your garden variety
peripheral nerve block? To go on, is one type
of injection distal to the ankle joint (say for
example, an injection for plantar fasciitis)
really anymore difficult than another such as a
peripheral nerve block? Then why should these
particular injections be reimbursed at different
monetary amounts?

I feel It would make sense if the insurance
companies would generalize foot/ankle injections
and pay a straight fee for any injection distal
to the ankle joint. Then we wouldn't have to
micromanage the CPT codes based on the agent or
location injected.

David T. Taylor, DPM
Flint, MI

11/11/2004    Multiple Respondents

Controlled Studies for Neurolytic Injections (Michael Schneider, DPM)

RE: Controlled Studies for Neurolytic Injections
(Michael Schneider, DPM)
From: Multiple Respondents

A recent study everyone should see read is
Treatment of intermetatarsal Morton's neuroma
with alcohol injection under US guide: 10 month
follow-up in Eur Radiol (2004) 14:514-518 by
Ezio Fanucci et. al.

Under US guidance 30% ethyl alcohol injections
were injected four times at intervals of 15
days. The success rate was 90% in a 40 patient
study, which is similar to Dockery. I now use US
guidance for all of my sclerosing alcohol
injections on neuromas.

Michael B. DeBrule, DPM
Marshall, MN

Unfortunately, as with many different treatments
that we do on a regular basis, there are no true
controlled studies to verify the comparison of
one thing to another. This is true with dilute
alcohol (as it is with cortisone or even
surgery) for the treatment of nerve conditions.
When an insurance company decides not to pay or
requests a refund based on this statement, it is
difficult to fight. To say that a prospective
study is no good since it was not blinded with a
placebo rules out most good clinical papers on
any subject.

There are two other papers in the literature on
using dilute ethyl alcohol in the treatment of
intermetatarsal neuromas, but again, these are
prospective studies without placebo comparisons:

Masala S, Fanucci E, Ronconi P, Sodani G, et al:
Treatment of intermetatarsal neuromas with
alcohol injection under US guide. Radilo. Med.
(Torino). 2001 Nov-Dec;102(5-6):370-373.

Fanucci E, Masala S, Fabiano S, Perungia D,
Squillaci E, et al: Treatment of intermetatarsal
Morton's neuroma with alcohol injection under US
guide: 10-month follow-up. Eur. Radiol. 2004

Gary Dockery, DPM
Seattle, WA

Since the procedure code CPT 64640 is found in
the current CPT-4 coding manual, it is not
investigational. It has been in the books for
quite a few years. It standards for destruction
of a peripheral nerve by chemical, thermal means

I perform cryosurgery and use this code all the
time with many different insurance carriers and
have not been refused by any. I would certainly
object strongly to returning any payments made
to you for the services you have rendered.

Steven H. Goldstein, DPM
Livingstone, NJ

I read with dismay Dr. Schneider's posting. It
is apparent from reading postings are here that
many podiatrists are using these sclerosing
injections and having success. It is also clear
that insurance companies will do anything in
their power to deny claims if they can. My
knowledge of the sclerosing agents is limited to
Dr. Dockery's articles and the Vitamin B
injection written a long time ago in an article
in JAPMA. If we are lacking scientific studies -
we need to do them.

Many residency programs require as part of
graduating an article of publishable quality to
be written. So - to all the residency directors
out there - here are some ideas to pass on to
your residents. Neurolytic injections -
efficacy on neuromas/neuritis.

The issue should really be addressed.

Jeffrey Kass DPM
Forest HIlls, NY