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:
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:
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.
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.
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.
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:
|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)]|
|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|
|M25.361-M25.369||Other instability, knee|
|M25.561-M25.569||Pain in knee|
|M25.661-M25.669||Stiffness of knee, not elsewhere classified|
|M25.861-M25.869||Other specified joint disorders, knee|
|M66.0||Rupture of popliteal cyst|
|M67.361-M67.369||Transient synovitis, knee|
|M67.861-M67.869||Other specified disorders of synovium and tendon, knee|
|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|
|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|
Peer Reviewed Publications:
|Websites for Additional Information|
|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.|