Clinical UM Guideline


Subject:Injection Treatment for Morton’s Neuroma
Guideline #:   CG-SURG-25Current Effective Date:  01/13/2015
Status:ReviewedLast Review Date:   11/13/2014

Description

This document addresses the indications for injection treatment of Morton's neuroma, a common paroxysmal neuralgia affecting the web spaces of the toes.

Clinical Indications

Medically Necessary:

Injections of sclerosing (neurolytic), anesthetic or steroid agents are considered medically necessary for treatment of Morton's neuroma when all of the following conservative therapies have failed:

Not Medically Necessary:

Injection treatment of Morton's neuroma is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
64455Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma)
64632Destruction by neurolytic agent; plantar common digital nerve
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
355.6Lesion of plantar nerve (Morton's metatarsalgia, neuralgia, or neuroma)
  
ICD-10 Procedure[For dates of services on or after 10/01/2015]
3E0T33ZIntroduction of anti-inflammatory into peripheral nerves and plexi, percutaneous approach
3E0T3CZIntroduction of regional anesthetic into peripheral nerves and plexi, percutaneous approach
3E0T3TZIntroduction of destructive agent into peripheral nerves and plexi, percutaneous approach
  
ICD-10 Diagnosis[For dates of services on or after 10/01/2015]
G57.60Lesion of plantar nerve, unspecified lower limb
G57.61Lesion of plantar nerve, right lower limb
G57.62Lesion of plantar nerve, left lower limb
  
Discussion/General Information

A neuroma is typically described as a benign tumor of a nerve characterized by exuberant proliferation of nerve endings. Morton's neuroma is not a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. The cause of Morton's neuroma is unclear and most frequently develops between the third and fourth toes. Possible causes include nerve entrapment, the abnormal anatomy of the plantar nerve in this location, structural/mechanical foot abnormalities, trauma, or excessive pressure.

Multiple treatment approaches have been utilized for Morton's neuroma including conservative care, such as orthotics, padding, and alternative shoe styles to relieve the pressure on the forefoot. More invasive treatments include anesthetic blocks, sclerosing or steroid injections, and surgical excision of the painful nerve. The peer-reviewed literature contains varied conclusions. In a Cochrane review, Thomson and colleagues (2004) cited that there is insufficient evidence with which to assess the effectiveness of surgical and non-surgical interventions for Morton's neuroma and that well designed trials are needed to begin to establish an evidence base for the treatment of Morton's neuroma pain. Serial ethanol injection therapy has been reported as an effective alternative to surgical excision at 10 months follow-up (Fanucci, 2004). In a recent prospective case series, Gurdezi and colleagues (2013) reported on the long-term effectiveness of alcohol injection for Morton's neuroma (mean follow-up: 61 months, range, 33-73 months). Of the 45 individuals evaluable at 5 years, 16 had undergone surgical treatment and 13 individuals had only transient relief of symptoms (2 weeks or fewer). Only 29% (13 of 45) remained symptom free. The authors concluded that alcohol injection for Morton's neuroma does not offer permanent resolution of symptoms for most individuals and can be associated with complications such as immense pain at the time of injection despite local anesthetic infiltration (n=9 of 12 adverse events). Despite wide use of alcohol injection, no randomized, double blind, placebo-controlled study exists to verify the efficacy of this treatment in comparison to longstanding similar therapies such as corticosteroid injection for the treatment of Morton's neuroma.

Jain and colleagues (2013) reviewed the peer-reviewed published literature of the available treatment options for Morton's neuroma, stating current nonoperative treatment strategies include shoe-wear modifications, custom made orthoses, and injections of local anesthetic agents, sclerosing agents, and steroids; however, despite a lack of high quality evidence-based research, some success was reported with use of local steroid injection, nerve decompression, and neurectomy.

The American College of Foot and Ankle Surgeons (ACFAS) addresses conservative and injection treatment of Morton's neuroma in their 2009 practice guideline: Diagnosis and treatment of forefoot disorders - Morton's intermetatarsal neuroma. The guideline identified the use of conservative care that focuses on elimination of pressure and irritation of the nerve. Other conservative care included injection therapies for pain relief using local anesthetic blocks, corticosteroids and neurolytic alcohol injections. However, overuse of corticosteroid injections was cautioned as it may result in atrophy of the plantar fat pad as well as joint subluxation.

An industry-sponsored randomized, double-blind, placebo-controlled, three-way cross-over single center clinical trial to characterize the phenotype in persons with Morton's neuroma and to explore the effect of local administration of lidocaine (NCT01298310) was completed on May 21, 2012. The trial results are currently unpublished in the peer-reviewed medical literature.

References

Peer Reviewed Publications:

  1. Bennett GL, Graham CE, Mauldin DM. Morton's interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int. 1995; 16(12):760-763.
  2. Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg. 1999; 38(6):403-408.
  3. Fanucci E, Masala S, Fabiano S, et al. Treatment of intermetatarsal Morton's neuroma with alcohol injection under US guide: 10-month follow-up. Eur Radiol. 2004; 14(3):514-518.
  4. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton's neuroma: a five-year follow-up. Foot Ankle Int. 2013; 34(8):1064-1067.
  5. Hassouna H, Singh D. Morton's metatarsalgia: pathogenesis, aetiology and current management. Acta Orthop Belg. 2005; 71(6):646-655.
  6. Hassouna H, Singh D, Taylor H, Johnson S. Ultrasound guided steroid injection in the treatment of interdigital neuralgia. Acta Orthop Belg. 2007; 73(2):224-229.
  7. Hughes RJ, Ali K, Jones H, et al. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. Am J Roentgenol. 2007; 188(6):1535-1539.
  8. Jain S, Mannan K. The diagnosis and management of Morton's neuroma: a literature review. Foot Ankle Spec. 2013; 6(4):307-317.
  9. Makki D, Haddad BZ, Mahmood Z, et al. Efficacy of corticosteroid injection versus size of plantar interdigital neuroma. Foot Ankle Int. 2012; 33(9):722-726.
  10. Markovic M, Crichton K, Read JW, et al. Effectiveness of ultrasound-guided corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int. 2008; 29(5):483-487.
  11. Mozena JD, Clifford JT. Efficacy of chemical neurolysis for the treatment of interdigital nerve compression of the foot: a retrospective study. J Am Podiatr Med Assoc. 2007; 97(3):203-206.
  12. Musson RE, Sawhney JS, Lamb L, et al. Ultrasound guided alcohol ablation of Morton's neuroma. Foot Ankle Int. 2012; 33(3):196-201.
  13. Wu KK. Morton neuroma and metatarsalgia. Curr Opin Rheumatol. 2000; 12(2):131-142.

Government Agency, Medical Society and Other Authoritative Publications:

  1. American College of Foot and Ankle Surgeons (ACFAS). Clinical Practice Guideline Forefoot Disorders Panel: Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. 2009; 48(2):251-256.
  2. AstraZeneca. A randomized, double-blind, placebo-controlled, three-way cross-over single center study to characterize the phenotype in patients with Morton's neuroma and to explore the effect of local administration of xylocaine (Lidocaine). NLM Identifier: NCT01298310. Last updated on May 21, 2012. Available at: http://www.clinicaltrials.gov/ct2/show/NCT01298310?term=MORTON%27S+NEUROMA&rank=2. Accessed on August 19, 2014.
  3. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma. Cochrane Database Syst Rev. 2004;(3):CD003118.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo. Morton's neuroma. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00158. Accessed on August 19, 2014.
  2. American College of Foot and Ankle Surgeons (ACFAS). Morton's neuroma (Intermetatarsal neuroma). Available at: http://www.foothealthfacts.org/footankleinfo/mortons-neuroma.htm. Accessed on August 19, 2014.
Index

Intermetatarsal Neuroma

History
StatusDateAction
Reviewed11/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Discussion, References, and Websites for Additional Information sections.
Revised11/14/2013MPTAC review. Added not medically necessary statement to Clinical Indications. Format change to medically necessary statement and Coding section. Updated Description, References, and Websites for Additional Information sections.
Reviewed11/08/2012MPTAC review. Updated Coding, Discussion, References, Websites for Additional Information and Index.
Reviewed11/17/2011MPTAC review. Discussion and References updated.
Reviewed11/18/2010MPTAC review. No change to criteria. References updated.
Reviewed11/19/2009MPTAC review. Discussion and References updated. Place of service removed.
Reviewed11/20/2008MPTAC review. References updated. Coding section updated to include 01/01/2009 CPT changes, removed HCPCS S2135 deleted 12/31/2008.
Reviewed11/29/2007MPTAC review. References updated.
Revised12/07/2006MPTAC revision. Deleted surgical procedures from criteria. References updated.
New09/14/2006MPTAC initial guideline development.