Diagnosis: Chronic Knee Pain.
Treatment: Pain Injection (64454 x 1).
The insurer denied the Pain Injection (64454 x 1), Pre-service.
The denial is overturned.

The member is a female with history of chronic bilateral knee pain due to severe Bilateral Knee osteoarthritis that has been ongoing for approximately more than 12 months with the pain affecting her functionality, especially ambulation.
She has tried and failed Physical Therapy, Tylenol, NSAIDs, intra-articular knee steroid injections, etc.

The request is for Right knee Genicular Nerve Block.

Yes, the requested Genicular Nerve Block (GNB) is medically necessary based on the current general standard of care bas stated below:
1) Is required to treat the diagnosis of Knee pain;
2) It was provided in accordance with generally accepted standards of medical practice;
3) it was the most clinically appropriate level of service that can be provided in this instance in terms of type, frequency, extent, site and duration;
4) It was not primarily for the convenience of a member, Physician or other healthcare Provider;
5) It was rendered in the least costly setting that is appropriate for the delivery of the procedure.

In this instance, the requested Genicular Nerve Block is therefore medically necessary as she has severe knee osteoarthritis, failed conservative measures and she is not a candidate for knee surgery.

In prospective randomized study, Guler et al. stated, "GNB is beneficial in reducing pain and increasing functional and physical capacity, with greater retention of effects on the physical capacity seen at 12 weeks."

In a randomized clinical trial, Elsaman et al concluded, "GNB has been approved for the treatment of pain in knee osteoarthritis. GNB in this study was able to control active knee arthritis and this effect persisted longer than intra-articular steroid injection."

The requested Genicular Nerve Block is not experimental/investigational as this is national standard practice for the treatment of severe chronic knee pain in a patient who has failed extensive conservative measures and who is not a surgical candidate and it has been demonstrated, through existing peer-reviewed, evidence-based, scientific literature to be safe and effective for treating Knee pain. It is therefore medically necessary as against what the health plan stated.

No, the health plan did not act reasonably in this instance and its decision has no sound medical judgment and not in the best interest of the patient because she has evidence of severe osteoarthritis for which she has tried and failed conservative measures as stated in the clinical summary and this is the less invasive next step in the management of her knee pain.

MRI (magnetic resonance imaging) of the RIGHT knee showed severe tricompartmental osteoarthritis with mucoid degeneration of the cruciate ligaments along with extensive tear of the menisci.