Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Osteoarthritis.

Treatment radiofrequency ablation of the nerves near the knees (pre-service).

The insurer denied coverage for radiofrequency ablation of the nerves near the knees (pre-service).

The denial is upheld.

Theis patient has a medical diagnosis of chronic severe left knee pain secondary to severe osteoarthritis of left knee. The treating provider is requesting plan approval for treatment with radiofrequency ablation of the nerves near the knees.

According to the clinical documentation provided for review, the treating provider is requesting plan approval for treatment with radiofrequency ablation of the nerves near the knees. The patient has the medical diagnosis of chronic severe left knee pain secondary to severe osteoarthritis of left knee. The patient has been seen and treated for chronic left knee pain. The Oswestry score is 40 percent. Pain is aggravated by activity. Treatment history has included rest, activity modification, bracing, physical therapy, and medications. On physical examination, there is knee joint tenderness to palpation with crepitus. Range of motion is restricted. The knee is stable to ligamentous testing. Knee osteoarthritis is diagnosed. The treating provider is recommending radiofrequency ablation of the nerves near the knees.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The decision is in line with generally accepted medical standards.      

Radiofrequency ablation of the nerves near the knees (pre-service) is not considered medically necessary for this patient.

Treatment history has included rest, activity modification, bracing, physical therapy, and medications. On physical examination, there is knee joint tenderness to palpation with crepitus. Range of motion is restricted. The knee is stable to ligamentous testing. Knee osteoarthritis is diagnosed. The treating provider is recommending radiofrequency ablation of the nerves near the knees. This is not necessary. In this case, there are no extenuating circumstances sufficient to warrant deviating from cited and applicable guidelines. This request is not strongly supported or backed by high-grade medical science-evidence. This request is deemed not medically necessary. Therefore, the request is denied and not medically necessary for this patient.

"Knee osteoarthritis is a common painful degenerative condition affecting the aging Canadian population. In addition to pain and disability, osteoarthritis is associated with depression, comorbid conditions such as diabetes, and increased caregiver burden. ... Despite its high cost and prevalence, controversy persists in the medical community regarding optimal therapies to treat knee osteoarthritis. A variety of medications like nonsteroidal anti-inflammatories and opioids can cause severe side effects with limited benefits. Total knee arthroplasty, although a definitive management, comes with risk such as postoperative infections, revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications because of a safer side effect profile and are much less invasive than a joint replacement. Platelet-rich plasma is beginning to replace the more common injectable therapies of intra-articular corticosteroids and hyaluronic acid, but larger trials are needed to confirm this effect. Small studies have examined prolotherapy and stem cell therapy and demonstrate some benefits. Trials involving genicular nerve block procedures have been successful. As treatments evolve, injectable therapies may offer a safe and effective pathway for patients suffering from knee osteoarthritis." (Billesberger, et al., 2020).                                                         

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for radiofrequency ablation of the nerves near the knees (pre-service) is upheld. Medical Necessity is not substantiated.