Diagnosis: Knee Pain

Treatment genicular nerve injection to treat knee pain

The insurer denied coverage for genicular nerve injection to treat knee pain.

The denial is upheld.

This patient has a history of super morbid obesity (BMI [body mass index] 58.6), sleep apnea, kidney stones, carpal tunnel syndrome, amputation below the knee on the left side with stump pain and phantom pain and has pain after a total right knee replacement.

She presented to the pain management physician's office for the evaluation of 10 out of 10 left knee pain. She takes Lyrica 600 milligrams (mg) per 24 hours without relief. She also tried Cymbalta and Amitriptyline without relief. She has tried heat and ice therapy and a home exercise program. The physician recommended obtaining magnetic resonance imaging (MRI) of the lumbar spine or a computed tomography (CT) scan in order to receive clearance for dorsal root ganglion stimulation. He also recommended genicular nerve blocks to treat knee pain. She has had 2 prior genicular nerve blocks with steroids which have provided long lasting 85% (percent) relief.

The use of genicular nerve blocks here is supported only with case series reports (1,2,3) with small numbers and limited follow-up.

There are evidence-based therapies available such as Spinal cord stimulation or intra-thecal pump therapy. The requested therapy is not medically reasonable or necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a genicular nerve injection to treat knee pain is upheld. Medical Necessity is not substantiated.