Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

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

This is a patient who has been diagnosed with complex regional pain syndrome (CRPS). A magnetic resonance imaging (MRI) lumbar spine showed facet arthropathy at lumbar vertebrae (L)4-5 and L4-sacral vertebrae (S)1 with neuroforaminal narrowing. The patient had pain in the medial knee. It was noted the patient had a steroid injection previously. The diagnosis was CRPS and arthritis of the left hip. The patient had a positive Patrick's test. The request is for pain injection (64454 x 1), which is under review.

An MRI left knee showed mild quadriceps tendinopathy and anterior cruciate ligament (ACL) strain of the left knee. There was no discrete tear of the medial meniscus and mild left extensor strain.

There is no justification or literature support for a genicular nerve block for CRPS or mild knee strains.

"Conclusion: Radiofrequency ablation (RFA) of the knee appears to be a viable and effective treatment option, providing significant benefit to well-selected patients lasting at least 3 months. More research is needed to better identify neural targets, refine selection criteria to include the use of prognostic blocks, optimize treatment parameters, and better elucidate relative effectiveness compared to other treatments." (Jamison, D. E. et al. 2018).

Chronic knee pain continues to cause increasing levels of functional deficits, mobility issues, and decreased quality of life in the United States. Initial treatment for knee pain consists of physical therapy, weight loss, medication management, injections, and radiofrequency ablation (RFA). Definitive treatment usually requires surgical management. Peripheral nerve stimulation (PNS) has been effective in the treatment of a variety of chronic pain conditions including the treatment of postoperative pain related to knee surgery. We describe the case of a patient who refused operative management as well as RFA of the genicular nerves and obtained significant pain relief from PNS of the superior lateral genicular nerve and the saphenous nerve for severe knee pain caused by osteoarthritis." (Hasoon, J. et al. 2021).

Pain injection (64454 x 1) does not have final approval from the appropriate regulatory bodies for this diagnosis.

It is an approved procedure for specific indications--i.e. osteoarthritis, post total knee replacement knee pain, but not for the patient's diagnoses.     

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

The patient has a diagnosis of sympathetically mediated pain, for which the requested injection is not indicated.     

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

This is not an appropriate treatment for chronic regional pain syndrome (CRPS).     

There are not adverse risks increased over standard treatment/services; however, the treatment is not indicated for the patient's diagnoses.     

The requested service is not indicated for CRPS. As such, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

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 not substantially increased over standard treatments.