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Genicular nerve block denial and appeal

2/27/2021

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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 Nerve (image below)

GENICULAR NERVE BLOCK DENIAL AND APPEAL
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!
Searched Keywords: GENICULAR NERVE BLOCK DENIAL AND APPEAL CPT BILLING CODE 64454
How to Get Paid for Genicular RFA Ablation Denial
How to Get Paid for Genicular RFA Ablation Denial
Need help how to Appeal your claims? Contact Us today!
Need help how to obtain Pre-determination before you render the Genicular Nerve Block to your patients? You should contact us today!

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Searched Keyword: Revenue Cycle Management Company for Interventional Pain Management
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    ABOUT THE AUTHOR:
    Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Medical Practice Consultant.

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  • About
  • Let's Meet in Person
    • 2023 ORTHOPEDIC VALUE BASED CARE CONFERENCE
    • 2023 AAOS Annual Meeting of the American Academy of Orthopaedic Surgeons
    • 2023 ASIPP 25th Annual Meeting of the American Society of Interventional Pain Management
    • 2023 Becker's 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference
    • 2023 FSIPP Annual Conference by FSIPP FSPMR Florida Society Of Interventional Pain Physicians
    • 2023 New York and New Jersey Pain Medicine Symposium
  • BLOG
  • Testimonials
  • FREE ASSESSMENT
  • Readers Questions
  • Resources
  • Medical Scribes | GoHealthcare Practice Solutions
  • Non-clickable Page