For years, one of my patients lived with chronic pelvic pain that felt like a hot poker in her vagina. After I performed a targeted nerve block with numbing medication, her pain disappeared. Through tears, she told me something I have heard from patients again and again: “I forgot what it’s like to not have pain. Thank you.”
A peripheral nerve block delivers numbing medication around a nerve to interrupt pain signals. It can help identify thell beyond the few hours before the numbing effect wears off
But beginning in late October, new Medicare policies issued by five regional Medicare Administrative Contractors (MACs) — which determine local oversight of 37 states and several U.S. territories — will restrict coverage for millions of patients with severe pain, including my patients, by cutting access to many peripheral nerve procedures used to diagnose and treat chronic pain.
The Centers for Medicare and Medicaid Services writes
The Centers for Medicare and Medicaid Services writes and oversees the Medicare rules. But because Medicare claims are so big, MACs are private companies that operate much of the machinery to apply those rules to individual health care providers and claims.
The final policy is slightly less restrictive than the proposal released in 2025, an important response to patients, physicians, and advocates who spoke up. But it still leaves patients with high-impact chronic pain at risk of losing access to treatments used for decades in pain care that can restore something as basic as the ability to sleep, go out and buy groceries, or spend hours every day without being consumed by pain.
The final policy excludes therapeutic procedures targeting nerves such as the pudendal nerve and ganglion impar, interventions used for some forms of severe pelvic pain. I have used these interventions to provide relief to patients who previously never had a break from pain, people for whom sitting, putting on a pair of pants, having sex, or simply getting through the day can be excruciating.
As a pain medicine physician, I worry
As a pain medicine physician, I worry that we are forgetting one of the central lessons of the opioid epidemic: People with chronic pain need alternatives to opioids and more individualized treatment options. Peripheral nerve interventions are not used in isolation. They are part of multimodal and multidisciplinary pain care, helping patients participate in physical therapy, restore function, decrease medications, avoid emergency room visits and hospitalizations, and sometimes delay or avoid more invasive procedures or surgery.
CMS contractors have a legitimate concern. In evaluating these procedures, they point to limitations in the evidence, including small studies, short follow-up periods, and uncertainty about whether benefits last. For several procedures, they concluded that the evidence was insufficient to support coverage.
But chronic pain presents a particular challenge for this style of evidence gathering. Pain is by definition a subjective experience, and every patient experiences pain differently. A treatment that produces limited benefit on average across a study population may provide profound relief to an individual. Population-level evidence matters, but it cannot always capture which patients experience a clinically meaningful benefit. And for the 1 in 4 U.S. adults living with unrelenting pain, even a few weeks or months of decreased suffering can help them feel like themselves again.
My mother taught me that long before I
My mother taught me that long before I became a pain physician. She is a brilliant cancer research scientist who has lived with chronic migraine and abdominal pain and, like so many patients I now see, often struggles to find physicians who understand her pain or know how to help her. She inspires me to keep looking for answers for patients who have spent years doing the same.
One of them was a remarkably healthy 87-year-old with severe bladder pain. By the time she came to see me, she had been passed from one doctor to another and was in despair. “I see it in their eyes,” she told me. “They don’t know what to do with me, and they look like they are trying to leave the room. I’ve never felt this way; people always want to be close to me.”
In my clinic, I meet patients no one knows how to help. And sometimes, the procedures I perform can be life-changing.
Some may question whether these procedures are used
Some may question whether these procedures are used too often, whether the evidence supporting them is strong enough, or whether financial incentives influence their use. Those are fair questions. Not every nerve block works, and Medicare should not pay indefinitely for treatments that do not help.
We need better evidence, including larger studies, longer-term patient follow-up, and federal funding to support this research. The answer to gaps in evidence is to seek that real-world evidence while at the same time preserving appropriate access to effective non-opioid treatments
But absence of perfect evidence should not be confused with absence of meaningful patient benefit.
One of my patients developed chronic pain after
One of my patients developed chronic pain after gynecologic surgery. After a pudendal nerve block, she told me: “I did not realize how different my life was because of the pain until you gave me the injection that took my pain away. I was able to wear pants, sit in a chair, and spend my day without being distracted by horrible pain.”
That may sound like a modest victory. To someone living with chronic pain, it is anything but. In a few weeks, this pain relief will no longer be accessible to her.
Individualized pain care should not depend on luck, who you know, your insurance coverage, or what is in your checking account. Pain does not always fit neatly into an insurance box of “approve” or “deny.” Effective pain care requires a broad treatment toolkit. That toolkit is meaningless if patients cannot access it.
As these new policies take effect, Medicare contractors
As these new policies take effect, Medicare contractors must reconsider restrictions as new evidence emerges, while researchers, clinicians, and specialty societies build and identify funding for the larger, longer-term studies Medicare says it needs. We need coverage standards that recognize clinically meaningful benefit while continuing to demand better evidence. We should not put the tools physicians use to relieve suffering out of patients’ reach.
Antje M. Barreveld is chief of pain medicine and anesthesiologist at Newton-Wellesley Hospital (Mass General Brigham) in Newton, Mass.; associate professor of anesthesiology at Tufts School of Medicine; and immediate past president of the American Academy of Pain Medicine.
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