Genicular RFA. Any input helpful!

[Dawkter]

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I am getting a lot of referrals for genicular blocks/RFA for patients who do not want to pursue TKA for a multitude of reasons and have exhausted meds, steroid injections, etc. This is coming with a lot of insurance denials for “experimental” therapy. Am I missing something on my documentation or is this to be expected?

 

[bedrock]

I am getting a lot of referrals for genicular blocks/RFA for patients who do not want to pursue TKA for a multitude of reasons and have exhausted meds, steroid injections, etc. This is coming with a lot of insurance denials for “experimental” therapy. Am I missing something on my documentation or is this to be expected?

Might want to an SDN search on the topic.

Short answer
1-only regular Medicare covers genicular RFA.
2-Medicare advatange and commercial insurance do not cover genicular RFA

3- despite #2, most insurances do still cover genicular blocks.

 

[PinchandBurn]

Might want to an SDN search on the topic.

Short answer
1-only regular Medicare covers genicular RFA.
2-Medicare advatange and commercial insurance do not cover genicular RFA

3- despite #2, most insurances do still cover genicular blocks.

Sounds like options then are

1. Cash pay genicular RFA
2. PERIPHERAL stim of genicular. Nerves which I believe is covered. Has this been your experience? I haven't tried #2 yet. But for many patients cash isn't an options.

3. Has anyone tried to repeat genicular blocks but with steroids to give longer relief. What's the frequency this can be repeated?

 

[Ducttape]

nah...

most of these Advantage programs have declared peripheral stim to be "experimental".

and in this particular circumstance, there is some validity to that argument...


yes yes someone will argue that there is some evidence for peripheral stim for diseases like occipital neuralgia....

specifically, chronic knee pain is not part of the ASPN guidelines.

 

[lobelsteve]

nah...

most of these Advantage programs have declared peripheral stim to be "experimental".

and in this particular circumstance, there is some validity to that argument...


yes yes someone will argue that there is some evidence for peripheral stim for diseases like occipital neuralgia....

specifically, chronic knee pain is not part of the ASPN guidelines.

ASPN Guidelines? I thought that was a marketing brochure for industry.

 

[Ducttape]

yes. and if they dont have PNS for chronic knee pain, then i would consider it definitely experimental....

and yes, i have seen a patient with a failed PNS for osteoarthritis...

 

[runfastnow]

Echo the above.

In my experience - does not work great for knee OA. Better success with painful hardware, etc.

 

[Orin]

I am getting a lot of referrals for genicular blocks/RFA for patients who do not want to pursue TKA for a multitude of reasons and have exhausted meds, steroid injections, etc. This is coming with a lot of insurance denials for “experimental” therapy. Am I missing something on my documentation or is this to be expected?

I'm doing fine with Medicare/Medicaid but the commercial payors are a challenge. If I can't do it, I send it on to my IR team for ? GAE.

PNS I will use for post-TKA pain but generally not just severe OA pain, but it's not any easier to get that covered.

 

[powermd]

Just an update on this one. I just got off the phone with Aetna for a patient with their advantage HMO. They're saying 64624 is covered without a precert.

 

[lobelsteve]

Just an update on this one. I just got off the phone with Aetna for a patient with their advantage HMO. They're saying 64624 is covered without a precert.

Covered, but they just won't pay you after the fact.

 

[powermd]

Covered, but they just won't pay you after the fact.

When you say the don't pay, are you saying they just ignore the bill?

I offered to do the procedure if the patient leaves a $500 deposit, returnable if the insurance pays. We'll see what he says.

 

[BobBarker]

I did genicular blocks on a patient with Aetna. No auth required. But not covered, so didn’t get paid

 

[Tboned]

I did genicular blocks on a patient with Aetna. No auth required. But not covered, so didn’t get paid

I’ve seen the same with Intracept. “No auth required”.
Intracept listed as experimental/investigational. Experimental/investigational not covered/paid.
yah, no thank you.



Also I’m told from my business office that it’s illegal to to have the patient pay cash when something is approved by insurance but they wont pay or only pay partial costs. I’m sure others know more about this stuff than I, but essentially if you have an approved procedure and you move forward with it, then you accepting the contractual agreement and that might mean no beans. Not sure if directly applicable to the deposit situation @powermd it thought I’d mention. We are actively working through this situation for an Intracept patient. Worth discussing if others can chime in!

 

[RoloTomassi]

I’ve seen the same with Intracept. “No auth required”.
Intracept listed as experimental/investigational. Experimental/investigational not covered/paid.
yah, no thank you.



Also I’m told from my business office that it’s illegal to to have the patient pay cash when something is approved by insurance but they wont pay or only pay partial costs. I’m sure others know more about this stuff than I, but essentially if you have an approved procedure and you move forward with it, then you accepting the contractual agreement and that might mean no beans. Not sure if directly applicable to the deposit situation @powermd it thought I’d mention. We are actively working through this situation for an Intracept patient. Worth discussing if others can chime in!

The way I understand it, for Medicare patients, you can't take cash for covered procedures if you are opted in. You can have them sign an ABN for things that are not covered. Non-Medicare you can do whatever you want.

 

[powermd]

I'm still trying to understand what you guys mean when you say Advantage plans don't pay. Do the issue a denial letter? Do they pay, but at a rate of zero? Do they just ignore the claim and ghost you?

 

[gh963817]

Sounds like options then are

1. Cash pay genicular RFA
2. PERIPHERAL stim of genicular. Nerves which I believe is covered. Has this been your experience? I haven't tried #2 yet. But for many patients cash isn't an options.

3. Has anyone tried to repeat genicular blocks but with steroids to give longer relief. What's the frequency this can be repeated?

For those of you offering cash pay genicular RFA, whats a generic price range? I am trying to imagine a price that would make this procedure pencil out, but that number seems wildly high

 

[BobBarker]

$500

 

[gaschicago]

any advice on making this procedure more tolerable for the patient? Doing it in office but don't have staff to push IV meds. patients generally have not tolerated it well regardless of how much local and/or valium is given to them

 

[BobBarker]

It can be really painful.

 

[lobelsteve]

I use a total of 10cc 1% lido and 6cc 0.25% bupi for genicRF. No complaints.

 

[pastafan]

any advice on making this procedure more tolerable for the patient? Doing it in office but don't have staff to push IV meds. patients generally have not tolerated it well regardless of how much local and/or valium is given to them

Don't drive needles into periosteum.

 

[MitchLevi]

Lido 1% for the skin. Each site maybe 2.5cc.

Bupi 0.5% 1.5cc prior to burn.

No issues.

Valium 4-5mg.

 

[Ducttape]

the lowest superomedial site is most tender and the local anesthetic at this level can be exquisitely painful.

suggestions - start slightly lateral to the target spot on fluoro image, instead of pure gun barrel, where you can feel more subcutaneous tissue. less uncomfortable

you can try putting TAC on, but you would have to pretreat for a good 15 minutes.

needle bevel parallel to periosteum.

80 degrees.

i use 2% lido and 0.25% bupiv 2 ml for the local prior to lesioning.

if you look at this graphic, the areas we target are where geniculars go.
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[epidural man]

I use a total of 10cc 1% lido and 6cc 0.25% bupi for genicRF. No complaints.

You mentioned earlier you don’t do testing.

I did a case today and the guy was miserable. I thought he would do much better if I didn’t test and numbed with needle placement - perhaps I’ll start to skip the testing.

Have you changed thoughts on this?

 

[lobelsteve]

You mentioned earlier you don’t do testing.

I did a case today and the guy was miserable. I thought he would do much better if I didn’t test and numbed with needle placement - perhaps I’ll start to skip the testing.

Have you changed thoughts on this?

What are you testing for? Sensory stim is barbaric, motor stim ....well there are no motor nerves in the area.

 

[Orin]

What are you testing for? Sensory stim is barbaric, motor stim ....well there are no motor nerves in the area.

I used to do sensory stim but you end up chasing things all over.

I still do motor testing as it is still useful. 1-2 out of every 10 cases I'll get some local muscle fibers firing. Generally need to redirect more distal as it's the superior lesions that do it.

 

[lobelsteve]

I used to do sensory stim but you end up chasing things all over.

I still do motor testing as it is still useful. 1-2 out of every 10 cases I'll get some local muscle fibers firing. Generally need to redirect more distal as it's the superior lesions that do it.

No. You don’t. The peroneal, tibial, and femoral nerves are not in the trajectory of the needles for this procedure.

 

[Orin]

No. You don’t. The peroneal, tibial, and femoral nerves are not in the trajectory of the needles for this procedure.

No, unfortunately I do. It's nothing distal/in the foot and there is no gross limb movement, but I'll see the needle moving and the muscles locally at the needle tip firing.

 

[nvrsumr]

Likely just local muscle fibers not a named nerve with common placement

 

[lobelsteve]

Stimming the muscle at 2V. See it all the time in low BMI patients for lumbar spine

 

[MitchLevi]

I'm now only offering these under cash. I think we're charging $717 or something like that.

This one has did well at 80C for 60 sec x 3. Each minute I moved the probe a bit.

Someone posted an article in the past with new placement sites which were more inferior on the two superior needles. I tried those placements and had bad results so I'm back to the more traditional sites.

 

[painfree23]

I'm now only offering these under cash. I think we're charging $717 or something like that.

This one has did well at 80C for 60 sec x 3. Each minute I moved the probe a bit.

Someone posted an article in the past with new placement sites which were more inferior on the two superior needles. I tried those placements and had bad results so I'm back to the more traditional sites.

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U do these with local anesthesia or general?

 

[drusso]

ASPN Guidelines? I thought that was a marketing brochure for industry.

ASPN aspires to displace IPSIS.

 

[drusso]

Cash is king.

 

[MitchLevi]

U do these with local anesthesia or general?

Lidocaine 1% 5cc mixed with sodium bicarb 1cc. Put 2cc at each site in the skin and soft tissue.

Prior to lesion put 0.5% bupivacaine 1-2cc at each site after testing.

This is a very easy procedure that is not painful.

Valium 2-5mg at home right before you leave to come up here.

 

[lobelsteve]

ASPN aspires to displace IPSIS.

Money vs Science.

ASPN can displace ASIP, not ISIS

 

[painfree23]

Lidocaine 1% 5cc mixed with sodium bicarb 1cc. Put 2cc at each site in the skin and soft tissue.

Prior to lesion put 0.5% bupivacaine 1-2cc at each site after testing.

This is a very easy procedure that is not painful.

Valium 2-5mg at home right before you leave to come up here.

Geez I have patients who can barely tolerate the local with a 27g

 

[MitchLevi]

Put 1cc sodium bicarb in 5cc of lido. It helps.

 

[SC Tian]

the problem is if they failed RFA, then what?

 

[MitchLevi]

the problem is if they failed RFA, then what?

 

[SC Tian]

I was discussing with one of the surgeons specializing in peripheral nerves to do some genicular nerve neurectomy, see how that goes. 😉

 

[Ducttape]

or maybe you should be a multidisciplinary pain physician and offer treatments other than procedural....

 

[bedrock]

the problem is if they failed RFA, then what?

Must consider
1- technical failure
2- pain in knee areas not supplied by genicular nerves
3- neuropathic knee pain.

I hate doing genicular RFA due to low pay but if I do it , I never do just one lesion, as the nerve location may be variable so that addresses #1

If they fail genicular RFA, I often try lumbar sympathetic block. If that doesn’t even help briefly then I stop everything because the negative block means #2. I’ll give them tramadol to try and their PCP can refill it.

If they get several months of relief after LSB, then I repeat those.
If they get good but brief relief after LSB, yet fail neuropathic meds, then this is where it is reasonable to consider L3 and L4 DRG trial.

 

[SC Tian]

maybe not

Must consider
1- technical failure
2- pain in knee areas not supplied by genicular nerves
3- neuropathic knee pain.

I hate doing genicular RFA due to low pay but if I do it , I never do just one lesion, as the nerve location may be variable so that addresses #1

If they fail genicular RFA, I often try lumbar sympathetic block. If that doesn’t even help briefly then I stop everything because the negative block means #2. I’ll give them tramadol to try and their PCP can refill it.

If they get several months of relief after LSB, then I repeat those.
If they get good but brief relief after LSB, yet fail neuropathic meds, then this is where it is reasonable to consider L3 and L4 DRG trial.

thanks, actually what I am doing now, in the real world of the orthopedic group, those patients are really bone on bone, some had alignment deformities, and knee rfa does not work as well, i was considering doing phenol neurolysis, welcome comments!

 

[Ronin1]

You can try peripheral stim. Seems to work in my series n=4

 

[SC Tian]

how long does that last, no migration, wears outside battery?

 

[cowboydoc]

maybe not

thanks, actually what I am doing now, in the real world of the orthopedic group, those patients are really bone on bone, some had alignment deformities, and knee rfa does not work as well, i was considering doing phenol neurolysis, welcome comments!

Have you tried to get phenol recently? I gave up after layers of hassle.

 

[SC Tian]

one of my partner use phenol for spasticity, he will write a prescription for a patient to bring in the meds.

 

[Ronin1]

how long does that last, no migration, wears outside battery?

Nalu. Outside battery correct. Supposedly 18 years for the receiver

 

[lobelsteve]

I love when we think procedures done in the 90s that failed will somehow work now.