Therapeutic genicular blocks ?

[bedrock]

I have a patient who until recently was on commercial insurance. This covered genicular blocks but not ablations. So I did her blocks with dex and bup and she would get 6 months of relief each time, so we didn’t worry about a cash ablation.

She is now on Medicare. I’m happy to continue genicular blocks q 6 months and still postpone the ablation As long as Medicare is ok with this.

Anyone done repeated genicular blocks under Medicare and been paid each time?

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[kstarm]

any specific reason to choose dex in this case?

 

[Ferrismonk]

Medicare pays for RF, so you can do that if you wish.

As far as I know, Medicare doesn't say that the genicular blocks need to be without steroid, so I'd just add the steroid and see how it goes.

 

[lobelsteve]

any specific reason to choose dex in this case?

None. Why would anyone use dex anywhere besides TFESI?

 

[bedrock]

None. Why would anyone use dex anywhere besides TFESI?

Because it prolongs duration of blocks.

 

[Ducttape]

i think steve was talking about dex vs depo.

particularly since there are certain people who love depo in certain injections

 

[Ferrismonk]

None. Why would anyone use dex anywhere besides TFESI?

Cost can be a factor for those in private practice.

 

[bedrock]

Cost can be a factor for those in private practice.

True. Dex is damn cheap and good enough for prolonging a nerve block.

 

[MitchLevi]

I caused a substantial amount of fat necrosis 3ish years ago at the inframedial site. Prob the size of a quarter. Dex + 0.5% bupi.

 

[Agast]

As far as I know there is no local determination coverage for genicular nerve blocks, so there is nothing that compels you to do an RFA if you don’t want to

(Lack of LCD is why the replacement plans get away with not covering geniculars)

 

[oreosandsake]

I’d consider Revisiting your primary diagnosis

There are a lot of other structures in those areas

Pes anserine insertion
Infrapatellar saphenous n
Mcl

It’s tough for a nerve block to last that long. Not saying it doesn’t happen

 

[projectpat]

Medicare pays for RF, so you can do that if you wish.

As far as I know, Medicare doesn't say that the genicular blocks need to be without steroid, so I'd just add the steroid and see how it goes.

How you get this covered? Medicare A&B regularly denies genicular RFA.

 

[bedrock]

How you get this covered? Medicare A&B regularly denies genicular RFA.

I see Medicare advantage plans denying genicular RFA, but not regular Medicare.

 

[Agast]

How you get this covered? Medicare A&B regularly denies genicular RFA.

Who is your Medicare carrier? I know there are regional differences between Novitas, Noridian etc

 

[Ferrismonk]

You don't even need to get auth for genicular RF with straight Medicare. How are they denying this?

 

[MitchLevi]

I thought Medicare only paid for blocks. I only do RFA for cash bc of this. Been that way for like 2 or more yrs.

 

[SpineandWine]

I have a patient who until recently was on commercial insurance. This covered genicular blocks but not ablations. So I did her blocks with dex and bup and she would get 6 months of relief each time, so we didn’t worry about a cash ablation.

She is now on Medicare. I’m happy to continue genicular blocks q 6 months and still postpone the ablation As long as Medicare is ok with this.

Anyone done repeated genicular blocks under Medicare and been paid each time?

I’ve been paid
Medicare LCD do not allow for genic RFA- with Medicare, there is no auth for genic RFA so they’ll pay but could easily ask for it back since it’s against LCDs at some point in future

My group got royally ****ed by Medicare because we were doing iovera for long time and Medicare asked for all their money back

 

[bedrock]

Does Medicare always pay for the blocks?

I would love to make some or all of genicular RFA cash pay to be more safe.

 

[projectpat]

I thought Medicare only paid for blocks. I only do RFA for cash bc of this. Been that way for like 2 or more yrs.

This is the same for us. Blocks get covered. RFA does not. Practically have to abandon offering this option. Hospital setting so RFA is $2k cash after removing as many fees as I can. So very few pay that.

Who is your Medicare carrier? I know there are regional differences between Novitas, Noridian etc

Palmetto

 

[gaseous_clay]

I thought Medicare only paid for blocks. I only do RFA for cash bc of this. Been that way for like 2 or more yrs.

Only replacement plans have this issue. Straight Medicare pays for both.

 

[DoYouEvenLiftBro]

what about DRG?

 

[drusso]

Are they tender to palpation in the region over the area of the cluneal nerves?

 

[SpineandWine]

Are they tender to palpation in the region over the area of the cluneal nerves?

My nurse practitioner watched a podcast and we had a patient who had L1-S1 fusion who had buttock pain with no significant relief with SI injection

She looked me dead in the eye and asked if “I mean I am not the boss and do what you tell me but have you heard of cluneal neuralgia”
She wanted to STIM.

What podcast, who is teaching her such confidence about cluneal neuralgia

 

[lobelsteve]

Are they tender to palpation in the region over the area of the cluneal nerves?

Cluneal neuralgia, CRPS knee, SIJ instability, vertebrogenic LBP.

Industry sponsored Dx.

Similar to Thyroid eye disease. At least it is not just us.

 

[cowboydoc]

My nurse practitioner watched a podcast and we had a patient who had L1-S1 fusion who had buttock pain with no significant relief with SI injection

She looked me dead in the eye and asked if “I mean I am not the boss and do what you tell me but have you heard of cluneal neuralgia”
She wanted to STIM.

What podcast, who is teaching her such confidence about cluneal neuralgia

Sounds like a chiro/NP team! Didn’t know they are shifting into the stim world, but it was only a matter of time…

 

[nvrsumr]

That np would make partner in some practices..

 

[drusso]

Cluneal neuralgia, CRPS knee, SIJ instability, vertebrogenic LBP.

Industry sponsored Dx.

Similar to Thyroid eye disease. At least it is not just us.

 

[SpineandWine]

that left SI is really stable

 

[lobelsteve]

View attachment 387573

Now pain free, on no meds, and runs 5K regularly.

 

[SpineandWine]

Now pain free, on no meds, and runs 5K regularly.

Just to counter argue here.
How would one help out the patient in image there?

Opiates no research
Cluneal nerve stimulation no research
I’m sure adjuncts have been tried and failed

Meditation, acceptance and PT tried but patient miserable, depressed but psychology failed

 

[MitchLevi]

Just to counter argue here.
How would one help out the patient in image there?

Opiates no research
Cluneal nerve stimulation no research
I’m sure adjuncts have been tried and failed

Meditation, acceptance and PT tried but patient miserable

Unfortunately, you've got med management and that IMO is the only option.

I struggled not having another option for the first few years out of fellowship, but not so much now. I don't think we can help everyone.

I'd try to fill up your schedule with pts you can actually help, AND at the same time it needs to be pts with good insurance.

The pts in the image above will suck your soul from your body and you'll never make any money in the process. I realize how that sounds, but it is unfortunately the reality of medicine today IMO. If you're in private practice (I am), you can't see people like the one above unless you're offering opiates and that's all you're doing.

 

[Tramadeezy]

Just to counter argue here.
How would one help out the patient in image there?

Opiates no research
Cluneal nerve stimulation no research
I’m sure adjuncts have been tried and failed

Meditation, acceptance and PT tried but patient miserable, depressed but psychology failed

Buprenorphine

 

[lobelsteve]

Just to counter argue here.
How would one help out the patient in image there?

Opiates no research
Cluneal nerve stimulation no research
I’m sure adjuncts have been tried and failed

Meditation, acceptance and PT tried but patient miserable, depressed but psychology failed

The problem is not the patient, it is thinking you can actually help.

 

[Ducttape]

The problem is not the patient, it is thinking you can actually help.

especially thinking that magic juice can be found at the tip of a needle.



the patient may have failed at psychology, but psychology hasnt failed the patient. he probably needs to go beyond CBT towards other psychological treatments.


or just give him 240 percs with 90 valiums a month. and a few somas for whatever.