Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral knee genicular radiofrequency ablations. Findings:  The physician reviewer found that there is some support in current medical literature supporting bilateral knee genicular radiofrequency ablation in certain select patients diagnosed with knee osteoarthritis who have failed conservative treatment modalities, additional studies are warranted. Kidd and colleagues state, Genicular nerve radiofrequency ablation (GNRFA), including conventional, cooled, and pulsed techniques, has been used in the management of symptomatic knee osteoarthritis. This new and innovative treatment option has the capacity to decrease pain and improve function and quality of life in certain patients. GNRFA is reserved for patients with symptomatic knee osteoarthritis who have had failure of conservative treatment and have had failure of or are poor candidates for surgery. The authors further note that indications for the procedure may include: patients with symptomatic knee osteoarthritis that is recalcitrant to conservative modalities, typically with moderate-to-severe osteoarthritis for which surgery would be considered or has already been done; patients with a failed knee replacement for whom no identifiable cause of the pain at the site of the total knee arthroplasty has been diagnosed; patients who are not good surgical candidates because of medical comorbidities and/or a high body mass index (BMI); patients who want to avoid surgery; and patients who have had a previously GNRFA, as this procedure can be repeated to address recurrent symptomatic knee osteoarthritis. The authors note that contraindications may include pregnancy, acute knee injury, unstable knee joint, chronic pain syndrome, psychological overlay, uncontrolled diabetes mellitus, bleeding disorder, presence of an implantable defibrillator, pacemaker, or a peripheral nerve stimulator, and current active, or history of, chronic knee infection. McCormick and colleagues report, Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Iannaccone and colleagues concluded, Radiofrequency ablation of genicular nerves can supply on average greater than 60% pain relief in our patient population for as long as six months. While noting that several randomized controlled trials demonstrate the superiority of genicular radiofrequency ablation compared with intra-articular steroid, viscosupplementation, and oral analgesics, Conger and colleagues conclude, Although genicular radiofrequency ablation appears relatively safe on the basis of the available data, additional large-scale studies are needed to provide greater confidence. While noting that there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of six months, Fogarty and colleagues conclude, Further research is likely to have an important impact on the current understanding of the long-term effectiveness of this treatment. In this case, the patient is undergoing treatment for bilateral knee pain and osteoarthritis of both knees. The records indicate that the patient underwent bilateral knee genicular nerve blocks and obtained 90% improvement in pain but only for a very short time period. Prior conservative treatment includes knee corticosteroid injections, with loss of efficacy, and physical therapy in 2020 with minimal improvement in pain. However, there is no indication of a recent trial and failure of conservative treatment including medications or physical therapy prior to this request for genicular nerve radiofrequency ablation to bilateral knees. Furthermore, while there is some support in current medical literature for genicular nerve radiofrequency ablation in patients with knee osteoarthritis that are recalcitrant to conservative modalities, given that there is a need for additional large-scale studies to provide greater confidence for genicular radiofrequency ablation, the requested service is not medically indicated. Therefore, bilateral knee genicular radiofrequency ablations are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.