Medical Policy

 

Subject: Genicular Nerve Blocks and Ablation for Chronic Knee Pain
Document #: SURG.00142 Publish Date:    03/29/2017
Status: Reviewed Last Review Date:    02/02/2017

Description/Scope

This document addresses genicular nerve blocks and genicular radiofrequency ablation, also called genicular neurotomy, genicular denervation or cooled radiofrequency therapy, as a treatment for the management of chronic knee pain.

Note: Please see the following related documents for additional information:

Position Statement

Investigational and Not Medically Necessary:

Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following:

Rationale

Genicular nerve blocks and genicular radiofrequency ablation are being evaluated in the treatment of chronic knee pain for individuals that have not been effectively managed by pharmacologic or other alternative therapies. A search of the peer-reviewed medical literature identified numerous systematic reviews and practice guidelines evaluating the use of nerve blocks for the diagnosis and treatment of neuralgias and neuropathic pain conditions; however, there is a lack of adequately designed trials in the peer-reviewed literature concerning the use of genicular nerve blocks and radiofrequency ablation as treatments for chronic knee pain.

In a 2011 randomized controlled trial by Choi and colleagues, the authors investigated whether radiofrequency ablation applied to articular nerve branches (genicular nerves) was effective in treating chronic knee joint osteoarthritis pain. The 38 study participants (who had severe knee osteoarthritis lasting longer than 3 months) were randomized to two treatment arms; radiofrequency ablation (n=19) or control group (n=19). Using a visual analog scale, Oxford knee scores, and global perceived effect on a 7-point scale, measurements were taken at baseline, and at 1, 4, and 12 weeks following the procedure. At the 4-week point, the visual analog scores showed the radiofrequency group had less knee joint pain than the control group. Similar findings were noted in the Oxford knee scores. There were no post-procedure adverse events reported during the follow-up period. While this study showed pain reduction in those with chronic knee osteoarthritis pain, the authors concluded that "further trials with larger sample size and longer follow-up are warranted."

In a 2016 randomized study by Qudsi-Sinclair and colleagues, 28 participants with continued knee pain following total knee arthroplasty were evaluated after having received traditional radiofrequency (n=14) or local anesthetic and corticosteroid block of the genicular nerves in the knee (n=14). In this double-blind, randomized study, the participants were followed for 1 year. During the first 3 to 6 months, an improvement in joint function and a reduction in pain were shown, with the results being similar between the two treatment arms. While the study showed improvement in both groups, the sample size was small and the authors noted that further studies should be done with larger sample sizes to determine if there are are any long-term adverse effects.

Currently other published studies either lack control groups or have serious methodologic problems that prevent the drawing of treatment-guiding conclusions from their results.

Background/Overview

Chronic osteoarthritis of the knee is one of the most common diseases of advanced age. With up to 20 million adults in the United States suffering from osteoarthritis of the knee, close to 700,000 cases progress to total knee joint replacement. Many individuals with chronic joint pain, however, are not candidates for invasive procedures due to body mass index, age and other comorbidities. Alternative therapies including arthroscopic debridement or injections are associated with less than optimal clinical outcomes. In addition to osteoarthritis, adults can experience knee pain due to a number of other causes, and an estimated 10-34 % of individuals experience long-term pain after a total knee replacement.

When an individual exhibits knee pain, the pain signals can be generated from the peripheral nerves innervating the knee including several branches of the genicular nerve. A diagnostic genicular nerve block consists of placing a small amount of local anesthetic, on the genicular nerves to determine if there is sufficient pain relief in the knee to justify performing a therapeutic neurotomy. Radiofrequency ablation of the genicular nerves is then performed to restore function and alleviate knee pain.

Definitions

Osteoarthritis: A degenerative condition of the joints that causes destruction of the material in the joints that absorbs shock and allows proper movement.

Radiofrequency ablation: A surgical procedure where diseased cells are destroyed using heat produced by high-frequency radio waves.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

CPT    
64450 Injection, anesthetic agent; other peripheral nerve or branch [when specified as genicular nerve block]  
64640 Destruction by neurolytic agent; other peripheral nerve or branch [when specified as ablation of genicular nerve(s)]  
64999 Unlisted procedure, nervous system [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)]  
     
ICD-10 Diagnosis  
M08.861-M08.869 Other juvenile arthritis, knee
M08.961-M08.969 Juvenile arthritis, unspecified, knee
M12.561-M12.569 Traumatic arthropathy, knee
M12.861-M12.869 Other specific arthropathies, not elsewhere classified, knee
M13.161-M13.169 Monoarthritis, not elsewhere classified, knee
M13.861-M13.869 Other specified arthritis, knee
M17.0-M17.9 Osteoarthritis of knee
M21.061-M21.069 Valgus deformity, not elsewhere classified, knee
M21.161-M21.169 Varus deformity, not elsewhere classified, knee
M21.261-M21.269 Flexion deformity, knee
M22.00-M22.92 Disorder of patella
M23.000-M23.92 Internal derangement of knee
M24.361-M24.369 Pathological dislocation of knee, not elsewhere classified
M24.461-M24.469 Recurrent dislocation, knee
M24.561-M24.569 Contracture, knee
M24.661-M24.669 Ankylosis, knee
M25.361-M25.369 Other instability, knee
M25.561-M25.569 Pain in knee
M25.661-M25.669 Stiffness of knee, not elsewhere classified
M25.761-M25.769 Osteophyte, knee
M25.861-M25.869 Other specified joint disorders, knee
M66.0 Rupture of popliteal cyst
M67.361-M67.369 Transient synovitis, knee
M67.461-M67.469 Ganglion, knee
M67.50-M67.52 Plica syndrome
M67.861-M67.869 Other specified disorders of synovium and tendon, knee
M70.40-M70.42 Prepatellar bursitis
M70.50-M70.52 Other bursitis of knee
M71.20-M71.22 Synovial cyst of popliteal space
M71.561-M71.569 Other bursitis, not elsewhere classified, knee
M92.40-M92.42 Juvenile osteochondrosis of patella
M92.50-M92.52 Juvenile osteochondrosis of tibia and fibula
M94.261-M94.269 Chondromalacia, knee
S80.00XA-S80.02XS Contusion of knee
S83.101A-S83.196S Subluxation and dislocation of knee
S83.401A-S83.92XS Sprain of knee
S87.00XA-S87.02XS Crushing injury of knee
T84.84XA-T84.84XS Pain due to internal orthopedic prosthetic devices, implants and grafts
Z96.651-Z96.659 Presence of artificial knee joint
   
References

Peer Reviewed Publications:

  1. Choi WJ, Hwang SJ, Song JG, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011; 152(3):481-487.
  2. Protzman NM, Gyi J, Malhotra AD, Kooch JE. Examining the feasibility of radiofrequency treatment for chronic knee pain after total knee arthroplasty. PM R. 2014; 6(4):373-376.
  3. Qudsi-Sinclair S, Borrás-Rubio E, Abellan-Guillén JF, et al. A comparison of genicular nerve treatment using either radiofrequency or analgesic block with corticosteroid for pain after a total knee arthroplasty: a double-blind, randomized clinical study. Pain Pract. 2016 Sep 19.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons. Osteoarthritis. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00227. Accessed on December 20, 2016.
  2. American College of Rheumatology. Osteoarthritis. Available at: http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Osteoarthritis. Accessed on December 20, 2016.
  3. Centers for Disease Control. Osteoarthritis. Available at: http://www.CDC.gov/arthritis/osteoarthritis.htm. Accessed on December 20, 2016.
Index

Osteoarthritis
Radiofrequency ablation

Document History
Status Date Action
Reviewed 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale and References sections.
New 02/04/2016 MPTAC review. Initial document development.