Is Genicular Artery Embolisation (GAE) covered by Medicare for osteoarthritis treatment?

Medicare Coverage for Genicular Artery Embolisation

Medicare coverage for Genicular Artery Embolisation (GAE) is not addressed in any established clinical guidelines, and no formal coverage determination policies are referenced in the available evidence. This is a critical gap because GAE is an emerging interventional procedure that falls outside traditional osteoarthritis treatment algorithms.

What the Evidence Shows About GAE

Clinical Efficacy

• GAE demonstrates substantial pain reduction in patients with refractory knee osteoarthritis, with systematic reviews showing VAS pain score reductions of 41 points at 6 months and 37 points at 12 months, representing large effect sizes (Hedges' g = -1.4 at 6 months) 1
• A prospective FDA-approved trial showed 68% of patients achieved ≥50% reduction in both WOMAC and VAS pain scores at 12 months, with technical success in 100% of cases 2
• The procedure targets synovial hypervascularity and neovasculature associated with osteoarthritis, with evidence of decreased nerve growth factor levels post-procedure that may contribute to pain reduction 3

Safety Profile

• Adverse events are predominantly minor, including transient skin discoloration, mild post-procedure knee pain, self-resolving focal skin ulceration (7 of 40 patients), and rare asymptomatic small bone infarcts 2
• No major adverse events have been reported across multiple studies involving over 900 patients 4, 1

The Coverage Problem

Why Guidelines Don't Address GAE

• Current osteoarthritis guidelines focus exclusively on established treatments: exercise, weight loss, NSAIDs, intra-articular injections, and joint replacement surgery 5, 6
• The 2023 ACR/AAHKS guideline explicitly discusses how insurance coverage determination policies often lack evidence-based foundations, with less than 10% of cited literature addressing effectiveness in patients with moderate-to-severe OA 5
• GAE is too new to be incorporated into formal guidelines, with the first significant clinical trials published only in 2021-2023 2, 3, 1

Clinical Context for GAE Use

• GAE is positioned for patients with moderate-to-severe knee OA (Kellgren-Lawrence grades 2-4) who have failed conservative therapy for >3 months 2, 3
• This represents the same population that guidelines recommend should proceed to joint replacement rather than delay for additional non-operative treatments 5
• The 2019 ACR guideline strongly recommends against other emerging interventions like platelet-rich plasma and stem cell injections due to lack of standardization and evidence 5

Practical Guidance

What to Do Now

• Contact your specific Medicare Administrative Contractor (MAC) to determine if a Local Coverage Determination (LCD) exists for GAE (CPT code 37242 or 37243 for peripheral arterial embolization)
• Request a pre-authorization or advance beneficiary notice (ABN) before proceeding, as coverage is likely to be determined on a case-by-case basis
• Document that the patient has failed conservative management including exercise, weight loss, NSAIDs, and intra-articular injections per established guidelines 5, 6

Key Documentation Requirements

• Evidence of refractory pain despite ≥3 months of guideline-concordant conservative therapy 2, 3
• Radiographic confirmation of moderate-to-severe OA (Kellgren-Lawrence grade 2-4) 2
• Documentation that the patient is either not a surgical candidate or wishes to delay joint replacement 5

Critical Caveat

The absence of GAE from clinical guidelines does not mean it lacks efficacy—it means the evidence is too recent for guideline incorporation. However, this same recency means Medicare coverage policies have not been established, creating a reimbursement barrier despite promising clinical data 4, 2, 3, 1, 7.