Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Pain injection- genicular nerve block.
The insurer denied pain injection- genicular nerve block.
The determination is upheld.

This is a patient who was diagnosed with bilateral knee pain and osteoarthritis. X-rays of the bilateral knees show tricompartmental degenerative changes moderately severe in the medial and patellofemoral joint compartments; small bilateral suprapatellar effusion: well-defined bony density adjacent lateral aspect head of right fibula may represent an old avulsion injury.

The patient was seen with complaints of chronic bilateral knee pain right greater than left. The pain was rated at 9/10. The patellofemoral joint spaces were also narrowed bilaterally. It was noted that the patient had received bilateral knee joint steroid injections which helped initially but the pain came back after a few days. The patient has participated in an activity restriction, home exercise program and physical therapy for the past 4 to 6 weeks with some benefits. The patient has been taking acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs). Her medications were listed as Abilify, albuterol, duloxetine, and Spiriva. The physical examination of the right knee shows a genu varus deformity. There was moderate tenderness over the medial joint space, decreased range of motion with flexion, strength 5/5, positive varus stress and instability, and normal sensation. The left knee revealed a genu varus deformity, crepitus, moderate tenderness over the patella, decreased flexion, positive varus stress, and instability. A right knee genicular nerve block was recommended.

There is a letter from the treating provider stating the patient has been under their care for severe bilateral knee pain secondary to osteoarthritis as confirmed by x-rays and physical exam. She has tried conservative management including physical therapy and/or occupational therapy for over 3 months, activity modification, NSAIDs, steroid injections, and viscosupplementation injections without improvement in pain which is rated at 8/10. She is not a candidate for surgery at this time, as it is reserved for patients with severe joint disease and persistent and unmanageable pain. The pain is affecting her activities of daily living. The provider is requesting a genicular nerve block which is under review.

The proposed health service or treatment pain injection-genicular nerve block is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The patient is noted to have chronic bilateral knee pain and imaging studies show moderately severe osteoarthritis. It was noted that she has tried conservative management including physical therapy and/or occupational therapy for over 3 months, activity modification, NSAIDs, steroid injections, and viscosupplementation injections without improvement in the pain, which is rated at 8/10. The provider states the patient is not a candidate for surgery as that is reserved for severe joint disease, although it would appear that the patient has moderately severe joint disease according to imaging. These injections are not recommended by evidence-based guidelines due to a lack of evidence regarding safety and efficacy, as well as no long-term studies with long follow-up periods available. There is no evidence to suggest that this procedure would be more likely to be beneficial than other standard treatments for this patient's condition.