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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral genicular radiofrequency ablation (RFA) with ultrasound guidance and fluoroscopy. In a study comparing the effectiveness of ultrasound guided versus blind genicular nerve block on pain, muscle strength with isokinetic device, physical function and quality of life in chronic knee osteoarthritis, Cankurtaran and colleagues found that both treatments were effective in reducing symptoms and improving physical function. Konya and colleagues reported in a study of 48 patients that in chronic refractory knee pain due to osteoarthritis, the application of radiofrequency ablation to the genicular nerve is an effective and safe treatment option in the medium-term to long-term. The authors noted that the mean visual analogue scale (VAS) scores were significantly lower at the one, three, and six-month evaluations compared with preoperative values.  The authors further noted a significant decrease in the Western Ontario and McMaster universities osteoarthritis index (WOMAC index) compared with preoperative values and decreases in opioid and nonsteroidal anti-inflammatory drug (NSAID) use. The authors reported that there were no serious complications encountered during or after the procedure. In comparing radiofrequency ablation to conservative analgesics and surgical interventions, El-Hakeim and colleagues reported statistically significant, superior pain relief with radiofrequency ablation at follow-up intervals. In this case, the patient has chronic bilateral knee pain due to osteoarthritis. She has tried and failed conservative care options, including intra-articular steroid injections, viscosupplementation injections, physical therapy, medication management, heat, ice and cupping therapy. In an undated letter, the provider reported that the patient has reported greater than 80% pain relief from a diagnostic right knee genicular nerve block. In this clinical setting, current medical literature supports the use of the requested service as safe, effective, and superior to conservative therapy, which this patient has already exhausted without clinically relevant relief or functional improvement. Therefore, bilateral genicular radiofrequency ablation (RFA) with ultrasound guidance and fluoroscopy is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested (bilateral genicular radiofrequency ablation (RFA) with ultrasound guidance and fluoroscopy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 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.