Bilateral Genicular NB/RFAs

[oneforfighting]

Patient has h/o bilateral TKA and comes in complaining of b/l knee pain. Has Medicare. Do you do bilateral genicular nerve blocks and then bilateral RFAs? Or treat one knee at a time? Can't seem to find this in the LCDs or anywhere.

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[Ferrismonk]

Patient has h/o bilateral TKA and comes in complaining of b/l knee pain. Has Medicare. Do you do bilateral genicular nerve blocks and then bilateral RFAs? Or treat one knee at a time? Can't seem to find this in the LCDs or anywhere.

You can, but it's a PITA. I do one at a time.

 

[Analgesia108]

I do unilateral - based on efficacy, do the other side

 

[oneforfighting]

You can, but it's a PITA. I do one at a time.

Does Medicare reimburse same either way? Or is there a modifier 50?

 

[callmeanesthesia]

I do blocks bilateral, ablation unilateral.

 

[Tboned]

I do blocks bilateral, ablation unilateral.

Me too

 

[bedrock]

I rarely do genicular RFA, but if someone truly needs bilateral genicular RFA, then I do both the blocks and the RFA bilateral, so that I spend the least amount of time possible on a low paying procedure (while still doing the procedure correctly)

 

[DrMDAware]

I’m starting to consider phenol for failed genicular RFA. Lots of ortho joints send to me so as long as their patients are better I don’t mind the lower reimbursement.

 

[Agast]

I rarely do genicular RFA, but if someone truly needs bilateral genicular RFA, then I do both the blocks and the RFA bilateral, so that I spend the least amount of time possible on a low paying procedure (while still doing the procedure correctly)

I do both at the same time as well. It doesn’t take too long, placement is nowhere near as finicky as lumbar RFA

 

[Orin]

Bilateral for both. Ultrasound or fluoro. Awake with ultrasound in clinic for the block most commonly and then IV sedation or under GA or anywhere in between for the RFA, normally with fluoro but okay for ultrasound if it's available.

 

[TIVAndy]

I do blocks bilateral, ablation unilateral.

same

 

[TIVAndy]

i've been doing bipolar burn at all 3 sites twice (pulling out few mm and repeat) - total 3 runs of burn so by genicular RFA takes a lot of time.

 

[Baron Samedi]

Bilateral for both. Ultrasound or fluoro. Awake with ultrasound in clinic for the block most commonly and then IV sedation or under GA or anywhere in between for the RFA, normally with fluoro but okay for ultrasound if it's available.

GA seems really overkill.

 

[SC Tian]

I’m starting to consider phenol for failed genicular RFA. Lots of ortho joints send to me so as long as their patients are better I don’t mind the lower reimbursement.

I have hard ordering phenol in the past three years, where did you get phenol?

 

[DrMDAware]

I have hard ordering phenol in the past three years, where did you get phenol?

Still talking to person who orders supplies and materials. That’s good to know it’s been hard to get.

 

[Orin]

GA seems really overkill.

It totally is but makes it way easier. LMA and go

 

[PinchandBurn]

I rarely do genicular RFA, but if someone truly needs bilateral genicular RFA, then I do both the blocks and the RFA bilateral, so that I spend the least amount of time possible on a low paying procedure (while still doing the procedure correctly)

How are you guys getting paid?

The genicular blocks get paid.

The rfa doesn't. Even at the ASC. HAD THE BILLLERS look at it.

 

[RoloTomassi]

It totally is but makes it way easier. LMA and go

When do you use LMA vs ETA? PMR background here

 

[bedrock]

How are you guys getting paid?

The genicular blocks get paid.

The rfa doesn't. Even at the ASC. HAD THE BILLLERS look at it.

I do little genicular RFA so haven’t checked much.
However my impression was that only straight Medicare plans were covering genicular RFA.
I tell any patient without straight Medicare that the blocks are covered but they have pay cash themselves for the ablations.

Are you seeing genicular RFA denials on patients with straight Medicare? (Not Medicare advantage)

 

[jqueb29]

When do you use LMA vs ETA? PMR background here

ETA for aspiration risk (gastroparesis, etc), or somebody I’m worried about being able to maintain spontaneous ventilation and adequate tidal volumes. Somebody with OSA and obesity, if you’re doing GA, probably need ETA, as you’re going to knock out their respiratory drive and then trying to do PPV via LMA you’re going to need high pressures that cause gastric insufflation.

 

[PinchandBurn]

I do little genicular RFA so haven’t checked much.
However my impression was that only straight Medicare plans were covering genicular RFA.
I tell any patient without straight Medicare that the blocks are covered but they have pay cash themselves for the ablations.

Are you seeing genicular RFA denials on patients with straight Medicare? (Not Medicare advantage)

I literally had my billers pull up 2 patients.

Same ones straight medicare...red,white, blue.

One paid. One didn't. Having my billers resubmit and see what happens.

They did say the LCD initially states its not necessary.

However, 36850 Article number# A57452. Under Medicare states it does...

It's a crapshoot. Will see what happens.

Had same for a UHC patient that is 4 months out. 100% better. They wanted studies etc. Appealed. Didn't pay. I think it works. Question is do patients just need to pay oop. It's sad...

 

[Multimodal]

we stopped doing genicular RFA in the surgery center partially due to lack of coverage and mainly because it didnt even pay $100. for those who are truly motivated to get it, we just do RFA in clinic now. that has weeded out alot of patients but those who are left tend to tolerate the procedure and do well in general. if we still have knee pain after genic RFA, we consider Nalu PNS. I think we will get another 1-2 years before medicare gets rid of genic RFA too like they did with SIJ RFA this year.

 

[DrMDAware]

we stopped doing genicular RFA in the surgery center partially due to lack of coverage and mainly because it didnt even pay $100. for those who are truly motivated to get it, we just do RFA in clinic now. that has weeded out alot of patients but those who are left tend to tolerate the procedure and do well in general. if we still have knee pain after genic RFA, we consider Nalu PNS. I think we will get another 1-2 years before medicare gets rid of genic RFA too like they did with SIJ RFA this year.

Not even 100$?! Wow. Please explain- probes expensive, takes too long, poor payor, etc. Please enlighten me

 

[TIVAndy]

we stopped doing genicular RFA in the surgery center partially due to lack of coverage and mainly because it didnt even pay $100. for those who are truly motivated to get it, we just do RFA in clinic now. that has weeded out alot of patients but those who are left tend to tolerate the procedure and do well in general. if we still have knee pain after genic RFA, we consider Nalu PNS. I think we will get another 1-2 years before medicare gets rid of genic RFA too like they did with SIJ RFA this year.

sorry to go off topic, is SIJ abalation gone for medicare also?

 

[SC Tian]

I reviewed 64624 in the past year, all paid, medicare fee 660, commercial about 1.5 times, medicare placement plan slightly less than 660. Wonder if you guys billed appropriately.

 

[SpineandWine]

sorry to go off topic, is SIJ abalation gone for medicare also?

Yes, SI RFA no longer covered

 

[bedrock]

I reviewed 64624 in the past year, all paid, medicare fee 660, commercial about 1.5 times, medicare placement plan slightly less than 660. Wonder if you guys billed appropriately.

Which commercial insurance companies paid for Genicular RFA?

 

[SC Tian]

we got paid from bcbs, uh, and bcbs medicare replacement here in New England.

 

[bedrock]

I reviewed 64624 in the past year, all paid, medicare fee 660, commercial about 1.5 times, medicare placement plan slightly less than 660. Wonder if you guys billed appropriately.

Are those global office based reimbursements or ASC pro fees? I expect those are office based global fees.

Are those for bilateral geniculars? Because a unilateral genicular RFA on medicare in office pays $397 as of 2022.

 

[SC Tian]

Are those global office based reimbursements or ASC pro fees? I expect those are office based global fees.

Are those for bilateral geniculars? Because a unilateral genicular RFA on medicare in office pays $397 as of 2022.

Sorry for the confusion, those numbers are facility fee for unilateral genicular rfa 64624 in ASC, i thought people discussing no benefits of doing those in facilities.

 

[PinchandBurn]

Sorry for the confusion, those numbers are facility fee for unilateral genicular rfa 64624 in ASC, i thought people discussing no benefits of doing those in facilities.

You're saying your facility got those payments? What about your pro fee?

 

[SpineandWine]

Blocks bilateral, burn unilateral.

I’m starting to consider phenol for failed genicular RFA. Lots of ortho joints send to me so as long as their patients are better I don’t mind the lower reimbursement.

never thought/heard of using phenol here.
Can you please explain this technique (views/pictures), how many cc’s you use, concentration of phenol etc. does this give you better results compared to ablation or you only use if ablation fails?

 

[Ducttape]

ugh. old treatment coming back.

would only use phenol for cancer pain. the post chemical neurotomy pain and lack of adequate treatment outweigh the temporary benefit of phenol.

it literally burns everything, nondiscriminatorily.

 

[SC Tian]

You're saying your facility got those payments? What about your pro fee?

Here are some pro payment in asc bcbs 379, uhc replacement 149, medicare 422, we have asc, so together it is profitable.

 

[DrMDAware]

ugh. old treatment coming back.

would only use phenol for cancer pain. the post chemical neurotomy pain and lack of adequate treatment outweigh the temporary benefit of phenol.

it literally burns everything, nondiscriminatorily.

I respectfully disagree. I’ll try to post the a study or two. You can mix phenol with contrast to more of a controlled spread.

 

[DrMDAware]

Chemical ablation of genicular nerve with phenol for pain relief in patients with knee osteoarthritis: a prospective study​

Pain Practice 21 (4), 438-444, 2021

Background​

Radiofrequency ablation of the genicular nerve is performed for knee osteoarthritis (KOA) when conservative treatment is not effective. Chemical ablation may be an alternative, but its effectiveness and safety have not been examined. The objective of this prospective open‐label cohort study is to evaluate the effectiveness and safety of ultrasound‐guided chemical neurolysis for genicular nerves with phenol to treat patients with chronic pain from KOA.

Methods​

Forty‐three patients with KOA with pain intensity score (Numeric Rating Scale, NRS) ≥ 4, and duration of pain of more than 6 months were considered for enrollment. Ultrasound‐guided diagnostic blocks of genicular nerves (superomedial, inferomedial, and superolateral) with 1.5 mL of 0.25% bupivacaine at each site were performed. Those who reported more than 50% reduction in NRS went on to undergo chemical neurolysis, using 1.5 mL 7% glycerated phenol in each genicular nerve. NRS and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed before intervention and at 2 weeks and 1, 2, 3, and 6 months following the intervention.

Results​

NRS and WOMAC scores improved at all time points. Mean pain intensity improved from 7.2 (95% confidence interval [CI]: 6.8 to 7.7) at baseline to 4.2 (95%CI: 3.5 to 5.0) at 6‐month follow‐up (P < 0.001). Composite WOMAC score improved from 48.7 (95%CI: 43.3 to 54.2) at baseline to 20.7 (95%CI: 16.6 to 24.7) at 6‐month follow‐up (P < 0.001). Adverse events did not persist beyond 1 month and included local pain, hypoesthesia, swelling, and bruise.

Conclusion​

Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6 months in most patients with a low incidence of adverse effects.

 

[DrMDAware]

Genicular nerve neurolysis with phenol for chronic knee pain: A case series​

Interventional Pain Medicine​

Volume 2, Issue 1, March 2023, 100182

The ideal volume and selection of neurolytic is the subject of debate. In previous case reports using 50–100% alcohol, we utilized 3 mL of 6% phenol in sterile water at each target nerve for each patient [[1], [2], [3], [4]].

While previous case reports have used alcohol for neurolysis, this report highlights the alternative of phenol for neurolysis. Some potential advantages to phenol include more localization given higher viscosity, local anesthetic properties to reduce procedural discomfort, and lower rate of neuritis compared to absolute alcohol [[9], [10], [11], [12]]. A potential disadvantage of phenol is that it must be constituted and stored, whereas absolute alcohol is readily available in vials.

 

[DrMDAware]

Chemical neurolysis of the genicular nerves for chronic knee pain: reviving an old dog and an old trick​

David R Walega, Zachary L McCormick

Pain Medicine 19 (9), 1882-1884, 2018

Image-guided genicular nerve radiofrequency neurolysis (RFN) has emerged as a novel method to treat knee pain from primary osteoarthritis (OA) and chronic knee pain following total knee replacement surgery (TKR), with decreased pain and improved function in the majority of properly selected patients [1, 2]. Despite the precision, reliability, safety, and clinical effectiveness of RFN, downsides of genicular nerve RFN are known: procedure and equipment costs, relatively low reimbursements, procedure-related pain often necessitating twilight anesthesia, and a nonresponse rate over 25%[2, 3].

We have found that image-guided chemical neurolysis (ChN) with alcohol or phenol compounds is a costeffective alternative to RFN for primary knee pain from OA and also as a salvage technique when RFN fails. Table 1 summarizes four cases from our respective clinical practices in which image-guided genicular nerve ChN successfully treated chronic knee pain. Despite variability in patient age, health status, severity of knee joint degeneration, and pre-vs post-TKR status, all patients experienced profound durable pain reduction and improved function following ChN, ranging from five to 12months of profound pain relief and improved knee function. Further, we found ChN to be safe in a chronically anticoagulated patient who could not safely discontinue anticoagulant use. We have seen no adverse events in any of these cases, and no case of dysesthesia, deafferentation pain, or chemical skin burns.

 

[MitchLevi]

Insurance pay for that?

 

[Ducttape]

i take it you havent used a lot of phenol and havent seen a lot of the consequences of use of phenol...

anyways:

Chemical ablation of genicular nerve with phenol for pain relief in patients with knee osteoarthritis: a prospective study​

not blinded. 6 month follow up only, no long term follow up which is where we see most of the post neuritis complications with the drug.

Chemical neurolysis of the genicular nerves for chronic knee pain: reviving an old dog and an old trick​

David R Walega, Zachary L McCormick

Pain Medicine 19 (9), 1882-1884, 2018

Image-guided genicular nerve radiofrequency neurolysis (RFN) has emerged as a novel method to treat knee pain from primary osteoarthritis (OA) and chronic knee pain following total knee replacement surgery (TKR), with decreased pain and improved function in the majority of properly selected patients [1, 2]. Despite the precision, reliability, safety, and clinical effectiveness of RFN, downsides of genicular nerve RFN are known: procedure and equipment costs, relatively low reimbursements, procedure-related pain often necessitating twilight anesthesia, and a nonresponse rate over 25%[2, 3].

We have found that image-guided chemical neurolysis (ChN) with alcohol or phenol compounds is a costeffective alternative to RFN for primary knee pain from OA and also as a salvage technique when RFN fails. Table 1 summarizes four cases from our respective clinical practices in which image-guided genicular nerve ChN successfully treated chronic knee pain. Despite variability in patient age, health status, severity of knee joint degeneration, and pre-vs post-TKR status, all patients experienced profound durable pain reduction and improved function following ChN, ranging from five to 12months of profound pain relief and improved knee function. Further, we found ChN to be safe in a chronically anticoagulated patient who could not safely discontinue anticoagulant use. We have seen no adverse events in any of these cases, and no case of dysesthesia, deafferentation pain, or chemical skin burns.

again, followed up only to 12 months max. some of these injections apparently only worked for 5 months. they do address and thus acknowledge that there are concerning side effects in the article, ie " no case of dysesthesia, deafferentation pain, or chemical skin burns" which is a telling comment to make. there were only 4 cases, so most probably just missed seeing these.

 

[Ducttape]

i know, these studies make it seem that phenol is easy, its a no brainer, nothing bad could come from its use.

here a primer of sorts on phenol worth reading before embarking on using it:

Phenol Nerve Block - StatPearls - NCBI Bookshelf

Phenol was once widely used for pain control. However, with the availability of better and safer agents, its use has declined. Phenol is primarily used by the pain specialist, anesthesiologist, and the radiologist. If phenol is used, the interprofessional team of the clinician, nurse, and pharmacist must be aware of the correct dosing and expected toxicity. The nurse must monitor the patient during injection and post-procedure. The pharmacist must confirm correct dosing. If there are complications, the interprofessional clinical team needs to be made aware of concerns quickly. While phenol is safe, there are reports about paralysis, hypotension, and apnea following the injection. Its efficacy as a pain-relieving agent also varies depending on the concentration used and volume. As such, for the best outcomes, an interprofessional team approach will lead to the best outcomes

 

[SC Tian]

ugh. old treatment coming back.

would only use phenol for cancer pain. the post chemical neurotomy pain and lack of adequate treatment outweigh the temporary benefit of phenol.

it literally burns everything, nondiscriminatorily.

Interesting, does phenol do anything to adjacent vascular, ligamental structures, my understanding it does not affect vessels, when we do celiac plexus block.

 

[DrMDAware]

Lol ok I can’t win with some of you.

I post three (recent!) studies to get some conversation going and it’s shot down with a comment about “it varies with concentration and amount.” Well duh.

So when you have a genicular RFA that fails (and McCormicks study makes a strong suggestion that more and more RFAs aren’t efficacious) what’s your next move? Suggest DRG or SCS and you’re called greedy and driven by profit. If you suggest phenol a cheap solution it’s called outdated and intolerable.

 

[DrMDAware]

i know, these studies make it seem that phenol is easy, its a no brainer, nothing bad could come from its use.

here a primer of sorts on phenol worth reading before embarking on using it:

Phenol Nerve Block - StatPearls - NCBI Bookshelf

No one said it was easy or a no brainer.

If it was easy or a no brainer there wouldn’t be a renewed interest in it.

 

[Ferrismonk]

I've never used phenol and don't really ever plan to, but I know someone who does from time to time. I'm also familiar with the basic concepts of chemical neurolysis, but my question is why do people add contrast to the phenol? What good does adding contrast into the phenol do? By the time you've injected it it's too late.

Also, I would caution it's use for genicular nerve ablation as the saphenous vein is periodically punctured with this procedure.

 

[lobelsteve]

I've never used phenol and don't really ever plan to, but I know someone who does from time to time. I'm also familiar with the basic concepts of chemical neurolysis, but my question is why do people add contrast to the phenol? What good does adding contrast into the phenol do? By the time you've injected it it's too late.

Also, I would caution it's use for genicular nerve ablation as the saphenous vein is periodically punctured with this procedure.

That would be a hard vein to reach if you are coming anterior to posterior and going for superior and inferior medial genic and superior lateral genic.

 

[bedrock]

Lol ok I can’t win with some of you.

I post three (recent!) studies to get some conversation going and it’s shot down with a comment about “it varies with concentration and amount.” Well duh.

So when you have a genicular RFA that fails (and McCormicks study makes a strong suggestion that more and more RFAs aren’t efficacious) what’s your next move? Suggest DRG or SCS and you’re called greedy and driven by profit. If you suggest phenol a cheap solution it’s called outdated and intolerable.

Another option instead of phenol is do the genicular RFA using a 16G bipolar needle technique.

Provides a much larger lesion compared to standard RFA/18G cannulae without the phenol risks.

 

[TIVAndy]

Another option instead of phenol is do the genicular RFA using a 16G bipolar needle technique.

Provides a much larger lesion compared to standard RFA/18G cannulae without the phenol risks.

this is what i do. i think the problem is that this nerve course is variable that's why we have lower success compared to spine neurotomy. hence we are trying to burn a larger lesion/consider phenol to capture the nerve.
some guys claim they can see the nerve on ultrasound - i see the genicular artery and if i get lucky i'll see a small nerve next to it but definitely not all the time. if someone has great technique/image of ultrasound they can share that would be great. i bet with larger people/poor ultrasound quality it becomes very hard to visualize consistently

 

[Ducttape]

Another option instead of phenol is do the genicular RFA using a 16G bipolar needle technique.

Provides a much larger lesion compared to standard RFA/18G cannulae without the phenol risks.

good idea, or if possible, cryo.

Lol ok I can’t win with some of you.

I post three (recent!) studies to get some conversation going and it’s shot down with a comment about “it varies with concentration and amount.” Well duh.

So when you have a genicular RFA that fails (and McCormicks study makes a strong suggestion that more and more RFAs aren’t efficacious) what’s your next move? Suggest DRG or SCS and you’re called greedy and driven by profit. If you suggest phenol a cheap solution it’s called outdated and intolerable.

"back in the day", phenol was used much more frequently.

there was no superiority or benefit to these patients, and in some cases it made things worse.

this is similar paradigm we see a lot - revisiting old treatments and thinking that they would work now, when they didnt in the past.

you wont like this, but one great option is not to stick a needle in the patient because you have to inject something

 

[MitchLevi]

Not quite sure why so many physicians lack the courage to tell pts there's nothing left to do.

"I'm sorry Mr. Jones, there's nothing else I can do about this. Here's Norco. Take it at 8AM, 1PM and before bed."

To quote the great Hawkeye (I miss him), "everything old is new again.