Genicular RFA. Any input helpful!

[callmeanesthesia]

Medicare LCD didn't give any guidance on this. I'll just wait until 6 months to burn again...

If no guidance then I don’t think it’s restricted. You could ask your billers too - sometimes they have access to coding edits that clarify things further.

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[Sadder]

Is anyone using these landmarks? I’m going to give them a try

Up

 

[callmeanesthesia]

Up

I’ve been doing it for a few months. Haven’t kept detailed track but seems to work at least as well as the conventional landmarks - I’d say roughly 80% successful. No complications so far.

 

[TIVAndy]

has anyone submitted genicular block/RF under new code yet? - do the private payors have the updated code now?

 

[callmeanesthesia]

has anyone submitted genicular block/RF under new code yet? - do the private payors have the updated code now?

Will try soon but would like to know the diagnostic block requirements prior to RF first... our billers told me it would likely be several months before the commercial payors added the code but I’ve read that several went ahead and just added it to their existing policies of experimental/not medically necessary...

 

[Sadder]

Male 55 years old. Injury and surgery 6 months ago. Complains of pain in the knee joint on the front surface below the patella pole and with knee flexion on the back side. 8-9/10. What is your opinion what kind of access? bipolar mode? monopolar?

 

[Orin]

Male 55 years old. Injury and surgery 6 months ago. Complains of pain in the knee joint on the front surface below the patella pole and with knee flexion on the back side. 8-9/10. What is your opinion what kind of access? bipolar mode? monopolar?

Have you done the blocks? That distribution described can be due to contributors via the saphenous and obturator more so than the usual sciatic based genics.

If you're doing a burn, the hardware is rather distant to most common ablation locations. You can put the grounding pad on the calf if you're worried about electrical issues, but it shouldn't be a problem.

 

[Sadder]

Have you done the blocks? That distribution described can be due to contributors via the saphenous and obturator more so than the usual sciatic based genics.

If you're doing a burn, the hardware is rather distant to most common ablation locations. You can put the grounding pad on the calf if you're worried about electrical issues, but it shouldn't be a problem.

I'm going to do the block tomorrow. In traditional points first

 

[Dansk2011]

I thought diagnostic blocks were required in order to proceed with rfa???!!! If that's not the case I feel like an idiot.

 

[callmeanesthesia]

I thought diagnostic blocks were required in order to proceed with rfa???!!! If that's not the case I feel like an idiot.

Current requirements are very unclear. I’ve been doing one set of blocks just in case they decide it’s required, but I’m not sure the actual clinical utility.

 

[Orin]

I thought diagnostic blocks were required in order to proceed with rfa???!!! If that's not the case I feel like an idiot.

For facets, yes; for any other peripheral nerve, no.

I go with at least one low volume local anesthetic block to make myself feel less profit driven about it

 

[Sadder]

after a small volume block of 1 ml in 3 points, according to the last method, we received 80% pain reduction for 5 hours. on Monday I plan rfa

 

[bm84]

Has anybody had any success getting commercial carriers to pay for genicular rfa? Had a patient who did with the block and the insurance is considering the rfa experimental. I’m reviewing articles to submit for evidence, if anybody has some experience getting these approved would be grateful if you could share some insight.

 

[lobelsteve]

Just tell them insurance is not covering it and have them pay a reasonable amount.

 

[buddababa]

Has anybody had any success getting commercial carriers to pay for genicular rfa? Had a patient who did with the block and the insurance is considering the rfa experimental. I’m reviewing articles to submit for evidence, if anybody has some experience getting these approved would be grateful if you could share some insight.

with this new code, im getting all commercial insurers declining to cover it; considering it experimental. And getting denials for already completed procedures submitted with the old code. Not sure what to do going forward. Im part of a hospital; so just setting a "cash price" isn't so easy yet.

 

[bm84]

Did a peer to peer with a cardiac surgeon, who I found to be quite unprofessional. Denied.

 

[painfree23]

Did a peer to peer with a cardiac surgeon, who I found to be quite unprofessional. Denied.

That’s Trash.

 

[geauxg8rs]

That’s Trash.

I like doing peer to peers with non pain docs who are reading from a paper and mispronouncing terms. My favorite way to get a denial

 

[SommeRiver]

Family medicine "peer" told me facetogenic pain can't exist in the buttocks.

 

[bm84]

I like doing peer to peers with non pain docs who are reading from a paper and mispronouncing terms. My favorite way to get a denial

Highlights of the conversation:

-He knows a lot about these..... smh
-He asked me If I would pay for it if it didn’t work. I told him I would! He was pretty shocked asked me if I was an employed physician and asked if I’d be willing to rewrite my contracts. I said let’s get the process started lol
-Claimed he was a patient advocate so I asked him as the patient’s advocate to please examine the patient before making medical decisions.

All in all a waste of time. I’ll offer a cash pay price to the patient and do it in office with po sedation and local

 

[Orin]

 

[callmeanesthesia]

Regarding the new targets, I’ve been doing those for about 8 months now - can’t say I’m impressed. If anything, I feel like I’ve actually seen less success. I can’t remember the last time I’ve had someone come back absolutely thrilled with their outcome. I think that was probably 20% or so with the way I was doing it before. On skinny knees the new landmarks are also harder because the needle endpoint can be really close to the skin, and I feel like they’ve been harder to fully anesthetize too. I’m doing conventional RF, not cooled. Anyone else have experience to share with these regarding targets?

 

[jsaul]

Regarding the new targets, I’ve been doing those for about 8 months now - can’t say I’m impressed. If anything, I feel like I’ve actually seen less success. I can’t remember the last time I’ve had someone come back absolutely thrilled with their outcome. I think that was probably 20% or so with the way I was doing it before. On skinny knees the new landmarks are also harder because the needle endpoint can be really close to the skin, and I feel like they’ve been harder to fully anesthetize too. I’m doing conventional RF, not cooled. Anyone else have experience to share with these regarding targets?

i use cooled RF and have been using the new targets for the past 6-8 months. And I too am not impressed. I was getting better results with the old targets with cooled than the new targets with cooled. Then again the old target slam dunk success rate was around 50-60 percent

 

[lonelobo]

Maybe it is time to realize it just doesn't work all that great, no matter what target we use.

 

[cowboydoc]

I've done a near wholesale switch to Iovera and doing cryo on the more superficial nerves, deeper geniculars if needed. Results are better than RF, getting 6 months on most responders. It's not great, but its better than RF in my hand. I think most of the reason for the difference is direct U/S visualization of the target.

 

[callmeanesthesia]

I've done a near wholesale switch to Iovera and doing cryo on the more superficial nerves, deeper geniculars if needed. Results are better than RF, getting 6 months on most responders. It's not great, but its better than RF in my hand. I think most of the reason for the difference is direct U/S visualization of the target.

Did some Iovera in fellowship and liked it. Tried to look into it in practice but in PP it doesn’t pencil out. At best it would have covered the cost of materials but probably not even that. Has pricing changed significantly in the past year or two?

 

[lobelsteve]

Hmm. Still doing ok with conventional RF just past midway from A to P.

 

[DODOCSS]

i use cooled RF and have been using the new targets for the past 6-8 months. And I too am not impressed. I was getting better results with the old targets with cooled than the new targets with cooled. Then again the old target slam dunk success rate was around 50-60 percent

agree, cooled and decent results w/ traditional

 

[callmeanesthesia]

Hmm. Still doing ok with conventional RF just past midway from A to P.

Conventional targets at the inflection point of the shaft and condyles, or the new ones at the lateral aspect of the condyles?

 

[lobelsteve]

Shaft condyle jcn. Apex of the curve.

 

[Sadder]

I also have +20% good results. This allows you to think that I will continue these targets

 

[Sadder]

Shaft condyle jcn. Apex of the curve.

 

[TIVAndy]

update on my technique. i now to bipolar burn on each target and burn twice (after pulling back few mm) this way i ensure a large burn.
anecdotally i see increase in success rate compared to my previous technique

 

[callmeanesthesia]

update on my technique. i now to bipolar burn on each target and burn twice (after pulling back few mm) this way i ensure a large burn.
anecdotally i see increase in success rate compared to my previous technique

How are you orienting the needles? Entry from AP or lateral? Needles both against the bone or one more lateral/medial?

 

[DrMDAware]

update on my technique. i now to bipolar burn on each target and burn twice (after pulling back few mm) this way i ensure a large burn.
anecdotally i see increase in success rate compared to my previous technique

Great.
1. Are you using the landmarks as per the study above?
2. Any sensory testing in awake patients?
3. 16 vs 18 vs 20?

 

[nvrsumr]

I use the above technique without bipolar. Start with patient supine and c-arm lateral. Use a 18g attached to a 10 cm syringe as a Fluoro marker to guesstimate final position and starting point. lateral to medial til a couple cm from end target noted above then hug os with curved tip to final placement. AP to confirm then burn.

Results either a hero or a zero.

 

[runfastnow]

Transitioned to the updated McCormick et al technique for superior medial/lateral and inferior medial. Don't mess with inferior lateral or patellar stuff. Per the paper below locations: D1, D2, C, I, and H.

50-60% success with OA non-surgical candidates.
90% success rate with post TKA CRPS and/or painful hardware.

Technical considerations for genicular nerve radiofrequency ablation: optimizing outcomes - PubMed

Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Radiofrequency ablation techniques targeting the genicular nerves have...

pubmed.ncbi.nlm.nih.gov

 

[painfree23]

Transitioned to the updated McCormick et al technique for superior medial/lateral and inferior medial. Don't mess with inferior lateral or patellar stuff. Per the paper below locations: D1, D2, C, I, and H.

50-60% success with OA non-surgical candidates.
90% success rate with post TKA CRPS and/or painful hardware.

Technical considerations for genicular nerve radiofrequency ablation: optimizing outcomes - PubMed

Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Radiofrequency ablation techniques targeting the genicular nerves have...

pubmed.ncbi.nlm.nih.gov

90% ?? I can’t say anything about anything I do..

 

[bedrock]

Transitioned to the updated McCormick et al technique for superior medial/lateral and inferior medial. Don't mess with inferior lateral or patellar stuff. Per the paper below locations: D1, D2, C, I, and H.

50-60% success with OA non-surgical candidates.
90% success rate with post TKA CRPS and/or painful hardware.

Technical considerations for genicular nerve radiofrequency ablation: optimizing outcomes - PubMed

Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Radiofrequency ablation techniques targeting the genicular nerves have...

pubmed.ncbi.nlm.nih.gov

I highly doubt the 90% with TKA CRPS. Those are the ones that fail for me.

Painful hardware often does well, however.

 

[TIVAndy]

I highly doubt the 90% with TKA CRPS. Those are the ones that fail for me.

Painful hardware often does well, however.

My theory is that post tka pain is often due to neuralgia at infrapatella saphenous( inferomedial genicular). U actually get good outcome just targeting that nerve

 

[TIVAndy]

Great.
1. Are you using the landmarks as per the study above?
2. Any sensory testing in awake patients?
3. 16 vs 18 vs 20?

1. Yes
2. No sensory.
3. 16 gauge

 

[runfastnow]

90% ?? I can’t say anything about anything I do..

Just giving you my experience. The McCormick technique greatly improved my outcomes. Certainly not changing it any time soon. I’m sure my outcomes will regress to mean at some point. Hopefully not. 🤷🏼‍♂️

 

[deleted131481]

Transitioned to the updated McCormick et al technique for superior medial/lateral and inferior medial. Don't mess with inferior lateral or patellar stuff. Per the paper below locations: D1, D2, C, I, and H.

50-60% success with OA non-surgical candidates.
90% success rate with post TKA CRPS and/or painful hardware.

Technical considerations for genicular nerve radiofrequency ablation: optimizing outcomes - PubMed

Genicular nerve radiofrequency ablation has emerged as a treatment option for patients with painful knee osteoarthritis who have failed conservative management but who may not qualify or wish to avoid a surgical procedure. Radiofrequency ablation techniques targeting the genicular nerves have...

pubmed.ncbi.nlm.nih.gov

Do you have the full article you can share?

 

[DrMDAware]

My theory is that post tka pain is often due to neuralgia at infrapatella saphenous( inferomedial genicular). U actually get good outcome just targeting that nerve

Interesting.

1. Do you ever do peripheral nerve stim for this?

2. Are the clinical exams consistent with your suspicion?

 

[TIVAndy]

Interesting.

1. Do you ever do peripheral nerve stim for this?

2. Are the clinical exams consistent with your suspicion?

yes. if they fail genicular RFA i offer PNS. i used to target other geniculars but i don't bother anymore. single lead at IPS gives you great outcome for post TKA pain. i've changed my practice based on meeting and discussion with andrea trescott, and to my surprise the outcome is really consistently good.

clinical exam - swelling/warmth, tenderness infrapatellar saphenous. of course chronic and has ruled out infection/other alignment/surgical issues by a joint surgeon

 

[bedrock]

Just giving you my experience. The McCormick technique greatly improved my outcomes. Certainly not changing it any time soon. I’m sure my outcomes will regress to mean at some point. Hopefully not. 🤷🏼‍♂️

I'd also appreciate that article if you have a pdf to share

 

[runfastnow]

Have full PDF that I can DM to whoever if willing to share e-mail. Saved locally on computer and SDN won't share it. Pic is the crux of the paper and the targets I use.

I only go for: C, D1, D2, H, and I. Tried B2 and F but ultimately very painful for patient and seemed to not change outcomes. Not messing with anything near the peroneal. Do motor stim prior to lesion (don't really have a good reason other than wanting something documented to CYA) then burn 90 sec 80*C at each location (with location H getting burn x 2) with 20 gauge 10 mm.

Happy with results since finding this technique. Judge success based on whether patient is satisfied. If need to repeat typically 10-12 month window. Have ortho colleague with high volume TKA and revision referrals that we've had good results for chronic knee pain, painful hardware, etc.. Only offer if failed legit PT, can't get off post-op opiates + Lyrica, and do not/want surgery. Try not to be overly aggressive about offering.

 

[DrMDAware]

Have full PDF that I can DM to whoever if willing to share e-mail. Saved locally on computer and SDN won't share it. Pic is the crux of the paper and the targets I use.

I only go for: C, D1, D2, H, and I. Tried B2 and F but ultimately very painful for patient and seemed to not change outcomes. Not messing with anything near the peroneal. Do motor stim prior to lesion (don't really have a good reason other than wanting something documented to CYA) then burn 90 sec 80*C at each location (with location H getting burn x 2) with 20 gauge 10 mm.

Happy with results since finding this technique. Judge success based on whether patient is satisfied. If need to repeat typically 10-12 month window. Have ortho colleague with high volume TKA and revision referrals that we've had good results for chronic knee pain, painful hardware, etc.. Only offer if failed legit PT, can't get off post-op opiates + Lyrica, and do not/want surgery. Try not to be overly aggressive about offering.

That’s for sharing.

What’s the rationale for not being overly aggressive about offering it? I imagine it’s because it’s not as slam dunk as other things we do.

 

[Ducttape]

er...
besides RFA of lumbar spine, what else do we do that is slam dunk?

maybe TFESI for acute radic that is going to get better anyways?

 

[buddababa]

Have full PDF that I can DM to whoever if willing to share e-mail. Saved locally on computer and SDN won't share it. Pic is the crux of the paper and the targets I use.

I only go for: C, D1, D2, H, and I. Tried B2 and F but ultimately very painful for patient and seemed to not change outcomes. Not messing with anything near the peroneal. Do motor stim prior to lesion (don't really have a good reason other than wanting something documented to CYA) then burn 90 sec 80*C at each location (with location H getting burn x 2) with 20 gauge 10 mm.

Happy with results since finding this technique. Judge success based on whether patient is satisfied. If need to repeat typically 10-12 month window. Have ortho colleague with high volume TKA and revision referrals that we've had good results for chronic knee pain, painful hardware, etc.. Only offer if failed legit PT, can't get off post-op opiates + Lyrica, and do not/want surgery. Try not to be overly aggressive about offering.

how are you billing for this ?

old school like each nerve or using the 64624 code for the bundle of genicular rfa?