CurrentKaiser PermanentePolicy N/A

Non-Surgical procedures for Knee Pain (Genicular interventions)

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.

Policy Summary

PayerKaiser Permanente

PolicyNon-Surgical procedures for Knee Pain (Genicular interventions)

Policy CodePolicy N/A

Change TypeMaterial updates: GAE criteria addednon-Medicare guidance revised

Effective Date04/01/2026

Next Review DateN/A

Key ActionWhen requesting review or authorization, include the last 6 months of clinical notes from the requesting provider and/or specialist.

SourceLink

POLICY UPDATE CHANGES

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.

04/01/2026GAE effective date

covered when criteria metMedicare coverage

not medically necessaryNon-Medicare stance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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 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.

Imaging and guidance requirements

Documentation Required

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

Prior Authorization

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.

GAE CPTs: 37242, 36245–36248
Genicular nerve CPTs: 64454, 64624, 64640
Use the Pre-authorization Code Check to confirm requirements by plan

Documentation Required

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

Procedure and diagnosis codes

Genicular nerve injection/ablation CPT codesCPT

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.

Genicular artery embolization CPT codesCPT

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.

Relevant ICD-10 diagnosis codesICD-10

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.

1–10 of 16

1/2

Diagnostic genicular block positive response — threshold

Positive response threshold>= 50% reduction in pain within 24 hours

Assessment timingPain reduction assessed in the 24 hours following the diagnostic genicular nerve block

PurposePositive response used to identify candidates for radiofrequency ablation

Definitions and procedure descriptions

Genicular nerve block — definition (diagnostic injection)

DefinitionPercutaneous injection of a local anesthetic (± steroid) targeted to genicular nerve branches to numb the knee and assess pain relief

Diagnostic usePerformed as a diagnostic step; patients with a positive response may be offered genicular nerve ablation

Procedure guidanceTypically performed under fluoroscopic or ultrasound guidance with AP and lateral views for needle placement verification

Cooled RFA (Coolief) — description and mechanism

Technique nameCooled radiofrequency ablation (Coolief/CRFA)

MechanismAn internally water‑cooled probe delivers RF thermal energy while circulating sterile water to modulate probe and tissue temperatures, enabling larger spherical lesions with reduced risk of excessive adjacent tissue heating

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

2026-04-01policy_effective_dateLatest

MPC-approved genicular artery embolization (GAE) criteria for treatment of knee osteoarthritis became effective after the required 60-day notice period.

2025-10-04MPC_action

MPC approved the proposed criteria for GAE for treatment of knee osteoarthritis with a 60-day notice requirement.

2023-09-05MPC_action