Genicular Nerve Block denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for genicular nerve block in right knee. Regarding the evidence surrounding genicular blocks, a randomized controlled trial (RCT) evaluated 59 patients who received either steroid and local anesthetic, or saline. The patients in the active group reported improvements in pain scores at two, four, eight, and 12 weeks. Another RCT compared ultrasound-guided block with steroid versus local anesthesia only and found that both groups improved significantly. A study evaluated the use of genicular blocks for patients with rheumatoid arthritis and found it to be an effective treatment option.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nerve block injections in both knees. In a double-blind, randomized controlled trial of local anesthetic, alone or in combination with corticosteroids for genicular nerve blocks, researchers concluded, “Ultrasound-guided genicular nerve block, when combined with a local anesthetic and corticosteroid, can provide short-term pain relief. However, the clinical benefit of corticosteroid administration was not clear in comparison with local anesthesia alone.” In a separate study on the efficacy of ultrasound versus fluoroscopy-guided genicular nerve block for chronic knee osteoarthritis, the same authors concluded, “Pain relief, functional improvement, and safety were similar between groups receiving ultrasound and fluoroscopy-guided genicular nerve blocks.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a genicular nerve block to nerves around the right knee. Findings: The physician reviewer found that the records indicate that this patient is being treated for chronic right knee pain, left knee arthritis, postoperative arthrofibrosis of the right knee, and post-traumatic arthritis in the right knee. She presented status post eight surgeries on her right knee with chronic pain, stiffness, arthrofibrosis, and ongoing discomfort. The patient’s physical examination revealed mild discomfort at rest and stiffness in the right knee with a restricted range of motion and well-healed surgical incisions. The provider noted that the patient walks with a slight limp. However, detailed documentation is not evident regarding a recent examination of the right knee range of motion values.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for genicular nerve blocks administered to each knee.A review of the medical literature concerning genicular nerve blocks for the treatment of osteoarthritis (OA) for the knee reveals that they are no more beneficial than other standard treatments. Currently, there is promising literature that genicular nerve blocks can help with knee OA in the short term. It has been determined that despite several small studies that demonstrate effectiveness, there is a need for larger randomized controlled studies to demonstrate the safety and effectiveness of genicular nerve ablation before this can become mainstream. The authors of a study concluded that genicular nerve blocks achieved results for knee functions and pain scores.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Genicular Nerve Block, then check the rights and deadlines that apply to your plan.