Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryoablation of the anterior femoral cutaneous nerve and infrapatellar branch of the saphenous nerve of the right knee. Findings:  The physician reviewer found that While there is some support for the requested treatment modality for patients who have failed standard medical therapy, there is a paucity of controlled studies in current medical literature supporting this treatment as more beneficial than standard treatments. In a review of ultrasound-guided peripheral nerve interventions for common pain disorders, Krishna Prasad and colleagues state, Saphenous nerve has been shown to supply the anteromedial aspect of the knee joint, and ultrasound-guided saphenous nerve block in the adductor canal has been shown to cause significant relief in chronic knee pain, lasting from less than a month to as much as more than four years. The authors further state, With pain relief, adequate physiotherapy and limb-strengthening exercises can be carried out, which is probably the cause for better functional status and prolonged decrease in pain. In a case series on cryoablation of the infrapatellar branch of the saphenous nerve identified by non-invasive peripheral nerve stimulator for the treatment of anterior knee pain, McLean and colleagues conclude, While acknowledging its limitations, we believe this case series demonstrates positive outcomes of a novel diagnostic and therapeutic procedure as part of a high-impact treatment in patients who had an inadequate response to rehabilitation and conservative treatment and limited alternative options for pain relief and functional improvement. Abd-Elsayed and colleagues report, Although our study was small, radiofrequency ablation showed a clear reduction in average pain scores in a subset of patients who had failed standard medical therapy with a reduction in pain at one-month follow-up with relief of symptoms sometimes lasting longer than 12 months. Dasa and colleagues state, Perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing total knee arthroplasty. Promising results from this preliminary retrospective study warrant further investigation of this novel treatment in prospective, randomized trials. In this case, the patient is undergoing treatment for chronic right knee pain and has a diagnosis of osteoarthritis of the right knee. The patient underwent cryoablation of the nerves at the right knee to treat longstanding right knee pain. However, while current medical literature notes some promising results, there is a lack of evidence to support the superiority of cryoablation of the anterior femoral cutaneous nerve and infrapatellar branch of the saphenous nerve over other standard therapies, and further investigation and randomized trials are warranted for this novel procedure. Therefore, cryoablation of the anterior femoral cutaneous nerve and infrapatellar branch of the saphenous nerve of the right knee was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the cryoablation of the anterior femoral cutaneous nerve and infrapatellar branch of the saphenous nerve of the right knee at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts 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.