Non-Surgical procedures for Knee Pain (Genicular interventions)
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Clinical review criteria for non-surgical genicular procedures for knee pain (including cooled RFA, genicular nerve ablation/neurolysis, and genicular artery embolization) used by Kaiser Permanente Washington for coverage determinations; affects providers requesting authorization and Kaiser members in that plan.
MPC approved the proposed criteria for genicular artery embolization (GAE) for the treatment of knee osteoarthritis; 60-day notice required, effective 04/01/2026.
MPC approved to adopt Neurolysis, Genicular Nerve: MCG A-1047 for non-Medicare patients.
Added MTAC review and MPC non-coverage decision for Coolief cooled RFA and retained non-coverage for genicular nerve ablation for non-Medicare patients.
Coverage criteria for genicular procedures
Coverage criteria for genicular procedures
Genicular nerve radiofrequency ablation (GNRFA) and related genicular procedures have differing coverage stances for Medicare and non‑Medicare members. The Medicare stance below applies when the applicable policy statements above are met. Non‑Medicare coverage and specific procedural notes follow.
GNRFA for persistent pain after total knee arthroplasty (post‑TKA) — Medicare members
- Documented persistent moderate to severe knee pain localized to the operated knee after total knee arthroplasty (TKA) that is not explained by infection, prosthesis loosening, malalignment, fracture, or other surgical complications.
Clinical evaluation and imaging (as appropriate) should exclude other treatable causes of post‑TKA pain.
- Presence of chronic pain despite appropriate conservative management post‑TKA, including but not limited to: physical therapy, activity modification, oral analgesics (including acetaminophen and NSAIDs unless contraindicated), and targeted intra‑articular or peri‑articular interventions as clinically appropriate.
Duration and specific therapies individualized; documentation of prior therapies and response required.
- Diagnostic genicular nerve block(s) demonstrate clinically meaningful temporary pain relief supportive of the target nerves as pain generators prior to performing neurolytic or thermal ablation procedures.
If blocks are performed, document timing, agent used, and degree/duration of symptom relief.
- Procedure is performed using appropriate CPT coding and documentation: examples include CPT 64624 (destruction by neurolytic agent, genicular nerve branches) or 64640 when applicable; ICD‑10 diagnosis codes such as M25.561 or M25.562 should correspond to laterality and clinical findings.
Medicare coverage requires adherence to applicable policy statements and coding guidance.
- For Medicare members, GNRFA post‑TKA meets Kaiser Permanente Medicare coverage criteria only when the specific clinical and documentation requirements in the applicable Medicare policy statements are satisfied.
Refer to the Medicare policy statements and local Medicare LCDs for additional requirements and coding specifics.
GNRFA and genicular injections — Non‑Medicare members
- Genicular nerve injections (CPT 64454) are considered not medically necessary for non‑Medicare members.
See non‑Medicare CPT list and policy rationale.
- Genicular nerve ablation, including thermal GNRFA and cooled RFA modalities (e.g., Coolief), is considered not medically necessary for non‑Medicare members due to insufficient evidence of long‑term safety and efficacy.
MTAC reviews concluded insufficient published evidence to support routine use; randomized trials are small and inconclusive.
Conservative therapies required before invasive interventions
Conservative therapies required before invasive interventions
Conservative measures should be tried prior to invasive genicular interventions. Covered only when ALL of the following are met:
ALL of the following
- Documented diagnosis of symptomatic knee osteoarthritis or post-surgical knee hemarthrosis as applicable.
- Evidence of an adequate trial of conservative therapies including at least two of the following: physical therapy (including aquatic therapy when appropriate), weight-loss program or documented weight-management counseling, bracing or orthosis, and regular use of oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs).
Specify dates and duration of each therapy in the medical record.
- At least one trial of intraarticular therapy when clinically appropriate (e.g., corticosteroid injection), unless contraindicated or clinically inappropriate, with documentation of response and dates.
Short-term analgesic effect expected; document reason if not tried.
- For knee hemarthrosis treated with genicular artery embolization: demonstration of synovial hypervascularity by angiography and failure of conservative measures (which may include ice, immobilization, compression, saline lavage, corticosteroid instillation, and selective COX-2 inhibitors such as celecoxib).
- Operator/performing provider documents that the member is a poor candidate for, declines, or has persistent symptoms despite optimization of conservative care prior to proceeding with invasive genicular procedures (e.g., genicular nerve RFA or genicular artery embolization).
Provider actions: Authorization, coding, and denial risk
Authorization and coding: Verify prior authorization requirements and submit applicable procedure and diagnosis codes with supporting documentation of prior conservative therapies. Denial risk: Non-Medicare genicular procedures (including genicular nerve radiofrequency ablation and genicular artery embolization) may be denied if documentation does not show required conservative therapy trials or if procedure is requested as an alternative to indicated surgery without review.
- Prior authorization required where plan policy or local contract requires review prior to genicular interventions; include dates and descriptions of conservative therapy trials in the request.
- Include CPT/HCPCS codes and ICD-10 diagnosis codes when requesting authorization; incomplete coding may delay review.
- Non-Medicare genicular procedures carry higher denial risk if conservative therapy criteria are not met or adequately documented.
Imaging and guidance requirements
Imaging guidance required for genicular procedures
Diagnostic genicular nerve blocks and cooled RFA must be performed under image guidance; the policy specifies fluoroscopic or ultrasound guidance with AP and lateral views to verify needle/probe placement.
- Use fluoroscopy or ultrasound guidance
- Confirm placement with AP and lateral views
Authorization, documentation, and denial risk
Verify authorization and CPT codes before scheduling
Obtain authorization and verify the applicable CPT codes prior to performing genicular artery embolization or genicular nerve procedures; the policy lists specific CPT codes for GAE and genicular nerve injections/ablations to be used for pre-authorization checks.
Required documentation with authorization request
When requesting review or authorization for these services, include the last 6 months of clinical notes from the requesting provider and/or specialist as part of the submission.
- Include last 6 months of clinical notes from requesting provider and/or specialist
Denial risk: non‑Medicare genicular procedures
For non‑Medicare members, requests for genicular nerve procedures (including cooled RFA/thermal GNRFA) may be denied because MTAC judged the published evidence insufficient; the policy considers these services not medically necessary for non‑Medicare patients.
- MTAC concluded insufficient published evidence for cooled RFA
- Genicular nerve injections and ablation are listed as not medically necessary for non‑Medicare members
Procedure and diagnosis codes
| 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. |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch. |
| 37242 | Vascular embolization or occlusion; arterial, other than hemorrhage or tumor. |
| 36245 | Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch. |
| 36246 | Selective catheter placement; initial second order abdominal, pelvic, or lower extremity artery branch. |
| 36247 | Selective catheter placement; initial third order or more selective abdominal, pelvic, or lower extremity artery branch. |
| 36248 | Selective catheter placement; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch. |
| M17.0 | Bilateral primary osteoarthritis of knee. |
| M17.10 | Unilateral primary osteoarthritis, unspecified knee. |
| M17.11 | Unilateral primary osteoarthritis, right knee. |
| M17.12 | Unilateral primary osteoarthritis, left knee. |
| M17.2 | Bilateral post-traumatic osteoarthritis of knee. |
| M17.30 | Unilateral post-traumatic osteoarthritis, unspecified knee. |
| M17.31 | Unilateral post-traumatic osteoarthritis, right knee. |
| M17.32 | Unilateral post-traumatic osteoarthritis, left knee. |
| M17.4 | Other bilateral secondary osteoarthritis of knee. |
| M17.5 | Other unilateral secondary osteoarthritis of knee. |
Definitions and procedure descriptions
Background — knee osteoarthritis and interventions
Knee osteoarthritis is a common, progressive degenerative joint disorder that is a leading cause of pain and functional limitation. First-line management emphasizes conservative measures such as physical therapy, weight loss, oral/topical NSAIDs, bracing/orthosis, and intraarticular injections (corticosteroid or hyaluronic acid). These therapies may relieve symptoms but do not reverse structural disease; for patients with severe disease or who fail conservative care, total knee arthroplasty is the definitive treatment though it may be unsuitable for some individuals.
Interventional genicular procedures (diagnostic genicular nerve blocks and radiofrequency ablation techniques) target sensory innervation of the knee to reduce pain. Diagnostic genicular nerve blocks are performed percutaneously and can predict response to ablation when a positive response is observed (commonly defined as ≥ 50% reduction in pain within 24 hours). Cooled RFA (Coolief/CRFA) was developed to create larger lesions while modulating probe and tissue temperatures, but randomized and comparative evidence remains limited and, per MTAC review, insufficient to establish clear benefit for many indications.
Not covered procedures
Cooled radiofrequency ablation (Coolief/CRFA) and other thermal genicular nerve radiofrequency ablation techniques for knee osteoarthritis in non-Medicare members are not covered due to insufficient published evidence demonstrating safety and long-term efficacy. MTAC reviews concluded there is inadequate evidence to determine the safety and effectiveness of cooled RFA for management of moderate to severe chronic OA knee pain and similarly found insufficient evidence to support thermal genicular nerve RFA for persistent post–total knee arthroplasty pain. As a result, these procedures are considered not medically necessary for non-Medicare patients under this policy.
Policy revision history and material changes
MPC-approved genicular artery embolization (GAE) criteria for treatment of knee osteoarthritis became effective after the required 60-day notice period.
MPC approved the proposed criteria for GAE for treatment of knee osteoarthritis with a 60-day notice requirement.
MPC approved adoption of Neurolysis, Genicular Nerve: MCG A-1047 for non-Medicare patients, aligning non-Medicare criteria to MCG guidance.
MTAC review for Coolief cooled RFA was added and MPC approved a non-coverage policy for this procedure (retained non-coverage for genicular nerve ablation in non-Medicare patients).
MPC approved to adopt a policy of non-coverage for genicular nerve ablation (GNA).
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