Anthem Blue Cross Connecticut SURG.00142 Genicular Procedures for Treatment of Knee Pain Form

This document addresses genicular procedures for knee pain. These include genicular nerve blocks, genicular nerve radiofrequency ablation (also called genicular neurotomy, genicular denervation, or cooled radiofrequency therapy), and genicular artery embolization for the management of knee pain.

This document does not apply to regional anesthetic blocks or acute surgical pain. This document does not apply to the use of peripheral nerve blocks (for example sciatic and/or femoral nerve blocks) as an adjunct to systemic analgesia in the perioperative period for major knee surgery.

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

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00155 Cryoneurolysis

Position Statement

Investigational and Not Medically Necessary:

Genicular nerve blocks are considered investigational and not medically necessary as a treatment for knee pain.

Genicular nerve radiofrequency ablation is considered investigational and not medically necessary as a treatment for knee pain.

Genicular artery embolization is considered investigational and not medically necessary as a treatment for knee pain.