Genicular nerve block denial and appeal

Effective January 1, 2020, we have now a specific code for the Genicular Nerve Knee Block and the Genicular Nerve Knee Ablation. You can read more about that change in our blog. CLICK HERE.

Understanding the Genicular Nerver (image below)

64454
Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed
64624
Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

I have been getting inquiries about their claims getting denied by the insurance payers including some contractors of Medicare. What I found is that, this is considered as Investigational and Experimental.

I commonly see the following guideline:
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:

• Degenerative joint disease;
• Osteoarthritis of the knee;
• As a treatment prior to knee replacement;
• As a treatment following knee replacement;
• As a treatment for individuals who are not candidates for knee replacement surgery.

I have seen two CMS Contractor who covers for this procedure based on Medical Necessity. See Group 1 Diagnosis Codes Cross Over:

Group 1 DX Codes:
M25.561 Pain in right knee
M25.562 Pain in left knee

Read more about guidelines:
National Government Services Inc Billing and Coding: Peripheral Nerve Blocks (A57452)
First Coast Service Options, Inc Billing and Coding: Peripheral Nerve Blocks (A57788)

More Guidelines from Payers which consider the procedure to be Investigational:

Aetna Healthcare
Anthem Blue Cross Blue Shield

How do you handle Denial and Appeal for Genicular Nerve Ablation or Genicular Nerve Block?

Here are my tips:

• Avoid the denials in the first place! by knowing your payers' guidelines;
• If the Provider says its Medically Necessary for the patient to receive the genicular nerve block or genicular nerve ablation, try getting a Predetermination based on Medical Necessity from your Payer! They will not allow you to submit Prior Authorization because for sure, it does not need Prior Authorization because its not a covered benefit based on their policy because the payer consider it "investigational" or "experimental"; Insist on reviewing Predetermination based on Medical Necessity instead!
• Already having denied claims? - pursue the claims by sending appeals, get your patient get involved with the appeals process. Be prepared with your medical documentation! How's the Patient's Pain Relief? Duration of Pain Relief? Improved ADL? - include that all in your documentation!

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