Clinical UM Guideline
|Subject:||Injection Treatment for Morton’s Neuroma|
|Guideline #:||CG-SURG-25||Current Effective Date:||01/13/2015|
|Status:||Reviewed||Last Review Date:||11/13/2014|
This document addresses the indications for injection treatment of Morton's neuroma, a common paroxysmal neuralgia affecting the web spaces of the toes.
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.
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.
|64455||Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma)|
|64632||Destruction by neurolytic agent; plantar common digital nerve|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|355.6||Lesion of plantar nerve (Morton's metatarsalgia, neuralgia, or neuroma)|
|ICD-10 Procedure||[For dates of services on or after 10/01/2015]|
|3E0T33Z||Introduction of anti-inflammatory into peripheral nerves and plexi, percutaneous approach|
|3E0T3CZ||Introduction of regional anesthetic into peripheral nerves and plexi, percutaneous approach|
|3E0T3TZ||Introduction of destructive agent into peripheral nerves and plexi, percutaneous approach|
|ICD-10 Diagnosis||[For dates of services on or after 10/01/2015]|
|G57.60||Lesion of plantar nerve, unspecified lower limb|
|G57.61||Lesion of plantar nerve, right lower limb|
|G57.62||Lesion of plantar nerve, left lower limb|
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.
Peer Reviewed Publications:
Government Agency, Medical Society and Other Authoritative Publications:
|Websites for Additional Information|
|Reviewed||11/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Discussion, References, and Websites for Additional Information sections.|
|Revised||11/14/2013||MPTAC 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.|
|Reviewed||11/08/2012||MPTAC review. Updated Coding, Discussion, References, Websites for Additional Information and Index.|
|Reviewed||11/17/2011||MPTAC review. Discussion and References updated.|
|Reviewed||11/18/2010||MPTAC review. No change to criteria. References updated.|
|Reviewed||11/19/2009||MPTAC review. Discussion and References updated. Place of service removed.|
|Reviewed||11/20/2008||MPTAC review. References updated. Coding section updated to include 01/01/2009 CPT changes, removed HCPCS S2135 deleted 12/31/2008.|
|Reviewed||11/29/2007||MPTAC review. References updated.|
|Revised||12/07/2006||MPTAC revision. Deleted surgical procedures from criteria. References updated.|
|New||09/14/2006||MPTAC initial guideline development.|