Diagnosis: Osteoarthritis.
Treatment: Genicular Nerve Injection (left knee).
The health plan denied: Genicular Nerve Injection (left knee).
The denial is: overturned.

This is a female patient with a diagnosis of bilateral primary osteoarthritis of the knee and pain in the left knee. Records indicate that a request for a genicular nerve block was denied by the insurance carrier as genicular nerve blocks for knee pain are considered experimental or investigational (unproven) and not covered by the health plan. Determination is under appeal, which is the subject of this review.

The patient was seen complaining of pain in the left knee. It was noted she received genicular radiofrequency ablation of the right knee and reports this helped greatly by 80%. She would like the same treatment for the left knee. Right knee pain is now 2/10. The left knee was reported as 2/10 but with activity can shoot up to 10/10. Medications include levothyroxine, metformin, alprazolam, zolpidem, and Pennsaid topical solution. The patient was noted to be morbidly obese with a body mass index (BMI) of 41.20. On examination reflexes were normal, and the sensation was normal. Left knee moderate tenderness to palpation over the medial joint space. Active range of motion 10-120°. Strength 5/5. There was moderate varus stability in the left knee and a positive varus stress test on the left. Negative McMurray's test. It was reported the patient has had greater than four weeks of physical therapy and home exercise, non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, and activity modification. It was noted if the patient gets more than 50% relief from the genicular nerve block, radiofrequency ablation will be considered. The provider performed a genicular nerve block.

The proposed health service or treatment Genicular nerve injection (left knee) is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease. The patient is noted to have complaints of chronic knee pain with osteoarthritis (although there were no imaging studies submitted for review) and reportedly has failed conservative treatment. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The ODG by MCG regarding genicular radiofrequency ablation (RFA) states "Not recommended for treatment of osteoarthritis of the knee." Guidelines do not recommend either genicular nerve blocks or radiofrequency ablation as this treatment has not been proven to be either safe or effective and there are no high-quality long-term studies with long follow-up periods available. There are alternative guidelines-supported treatment options that can be utilized. There is no evidence to suggest that the requested treatment genicular nerve injection would be more beneficial than standard treatment options.