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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for peripheral nerve destruction treatment of the left knee (CPT-77002) (CPT-64640). Findings:  The physician reviewer found that Findings: Two out of three physician reviewers found that the requested peripheral nerve destruction treatment of the left knee (CPT-77002) (CPT-64640) is not likely to be more beneficial for the patient than any other available standard treatments for the patients medical condition.Radiofrequency (RF) neurotomy of articular nerve branches in the knee (genicular nerves) is a potential therapeutic alternative for chronic pain associated with osteoarthritis of the knee, particularly for some older individuals with comorbidities who may not be good surgical candidates. Data for neurotomy are lacking, but RF neurotomy of genicular nerves led to some pain reduction and functional improvement in elderly patients with chronic knee osteoarthritis who responded positively to a diagnostic genicular nerve block. However, small sample size and short follow-up led to limited recommendation (Choi, W., et al.). A review of 13 studies of ablative or pulsed RF knee treatments suggested some benefit for relief of chronic knee pain over the short term, but only 2 studies were weak randomized controlled trials (RCTs), with the authors stating concerns over the quality of available evidence (Bhatia, A., et al.). A systematic review of 17 studies, including 5 small-sized RCTs of RF ablation for knee osteoarthritis, similarly concluded that there might be some promise up to 1 year with minimal complications, but most publications were of poor quality, precluding any broad conclusions (Gupta, A., et al.).In this case, the patient is being treated for chronic left knee pain secondary to osteoarthritis. The patients symptoms are activity limiting, and he has experienced good relief with genicular nerve blocks, but the duration of relief is not noted. Records suggest that blocks were performed within 4 weeks of each other. The medical literature provides low quality short term results regarding the requested procedure. The requested genicular radiofrequency ablation should be considered investigational in the knee until higher quality studies with longer follow-up periods are available, demonstrating long-term efficacy and possible adverse effects. Accordingly, the requested peripheral nerve destruction treatment of the left knee (CPT-77002) (CPT-64640) is not likely to be more beneficial for the patient than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for the patient than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.