Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: Complex regional pain syndrome of the left lower leg

Treatment: pain injection (64454 x 1)

The insurer denied coverage for pain injection (64454 x 1)

The denial is upheld

The patient was diagnosed with complex regional pain syndrome. The request is for pain injection (64454 x 1), which is under review.

A magnetic resonance imaging (MRI) of the left knee revealed chronic grade two (2) sprain at the distal tibia insertion of the left Anterior cruciate ligament (ACL), but with intact fibers throughout, nonspecific thin serpiginous isointense debris within adjacent anterior medial intercondylar notch suspicious for mildly displaced ACL fragment, but with differential including synovial scarring/ruptured plica; degeneration versus subacute contusion of the posterior horn and root of left medial meniscus without discrete surface tear, grade 1 subacute on chronic sprain of the posterior medial corner, and no focal chondral defect or effusion; and mild peri tendinitis/subacute grade 1 strains of the extensor mechanism of left knee. 

An MRI of the lumbar spine revealed degenerative changes of the lumbar spine with up to moderate foraminal narrowing; and no central canal narrowing. 

Physical exam revealed trace effusion; 0-120 degrees range of motion; 5/5 strength; sensation intact; 1A Lachman's; grade 1 posterior drawer; positive McMurray's/Thessaly; and 1+ patellar translation. X-rays revealed no fracture or dislocation; no degenerative changes; no malalignment; no obvious osseous abnormality; and otherwise unremarkable study. 

The patient has a past medical history of hypertension. The patient was diagnosed with medial meniscus tear, left; and left knee pain. The patient treated with injections, and medications.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes for patients with knee osteoarthritis. 

In this case, the patient has no evidence of knee osteoarthritis. Medical literature included within the medical documentation provided for review indicates genicular nerve blocks are appropriate for knee osteoarthritis. However, there is no evidence of diagnostic imaging substantiating knee osteoarthritis and subsequent pain.      

The pain injection (64454 x 1) does not need approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for pain injection (64454 x 1). 

The patient has no evidence of substantiated knee osteoarthritis. The patient was diagnosed with a medial meniscus tear and chronic regional pain syndrome (CRPS). X-Rays of the knee revealed no evidence of degenerative changes.     

The pain injection (64454 x 1) is not the best available treatment for this patient at this time.     

The adverse risks increased over standard treatment are not applicable for treatment measures, such as physical therapy. Physical therapy would be a first-line conservative treatment, reasonable to treat the diagnosis of a medial meniscus tear.     

The requested service is unlikely to be more beneficial than any of the standard treatments/procedures for this patient at this juncture. 

The patient was diagnosed with a medial meniscus tear and CRPS. There is a complete lack of knee osteoarthritis. Genicular nerve blocks may be supported for patients experiencing knee osteoarthritis. Standard of care treatments/conservative treatment measures appropriate for the diagnosis of knee pain and a medial meniscus tear include first-line medications such as non-steroidal anti-inflammatories (NSAIDs), a home exercise program, physical therapy, cortisone injections, etc.

In summary, the denial of pain injection (64454 x 1) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.