CMS was founded on one unshakable principle — that every Medicare beneficiary deserves equal access to medically necessary care, no matter their zip code. Yet today, that principle is being quietly eroded by a set of proposed Local Coverage Determinations (LCDs) from five Medicare Administrative Contractors (MACs). These draft policies would classify several established interventional pain procedures — including genicular radiofrequency ablation (RFA) for knee osteoarthritis — as “experimental” and deny coverage to millions of patients who live in certain regions.
If finalized, these policies would divide the nation into two Medicare systems: one where patients with chronic pain have access to evidence-based treatments, and another where they are left with only opioids or surgery.
The Science Has Been Ignored
Genicular RFA is not an experimental procedure. Multiple meta-analyses and systematic reviews — Almeida, Chou, Chen, Fogarty, and most recently Barreto et al. — have shown that RFA significantly reduces pain, improves function, and sustains benefit for up to a year in patients with knee osteoarthritis. ASPN’s STEP guidelines (2021) classify it as Level 1, Grade A — safe, effective, and a standard of care.
These findings are supported by real-world clinical experience across thousands of practices nationwide. Yet the MACs have chosen to disregard years of accumulated scientific data and professional consensus in favor of an arbitrary evidence threshold that even many surgical procedures could not meet. Worse still, they finalized their proposals while knowing that a major meta-analysis by Barreto et al. and new ASRA guidelines were imminent — evidence that could have informed a balanced policy.
A Tale of Two Patients
This controversy is not theoretical. Imagine two 72-year-old women with debilitating knee pain, both Medicare beneficiaries. One lives in Florida. The other lives in New York. The Florida patient, covered under First Coast Service Options, can receive an RFA procedure that safely restores mobility and cuts her opioid use. The New York patient, under National Government Services, is denied the same care for the same condition — because the procedure is labeled “investigational.”
This kind of arbitrary, geography-based discrimination has no place in a federal program. It undermines the very integrity of Medicare, replaces fairness with randomness, and punishes patients based solely on their address.
Violating CMS’s Own Rules
In Chapter 13 of the Medicare Program Integrity Manual, CMS requires that LCDs reflect the “standard of care for the community” and rely on the “totality of the evidence.” The MACs’ proposals do neither. Instead, they ignore both professional society guidelines and the real-world outcomes that define modern interventional pain management.
Such procedural disregard breaches not only CMS’s internal policy but also its ethical duty to beneficiaries. It effectively erects bureaucratic barriers between suffering patients and treatments that could restore their quality of life.
The Real Cost of Denying Care
By cutting off access to minimally invasive pain procedures, these LCDs will achieve the exact opposite of CMS’s stated goals: they will increase health care costs and opioid dependence. Patients denied RFA will face worsening pain, reduced function, and ultimately more invasive — and expensive — surgical options. The downstream costs will include higher rates of joint replacement, emergency visits, and opioid-related hospitalizations.
The notion that eliminating covered procedures will save money is not only misguided but dangerous. Denying proven therapies in the name of “evidence purity” while permitting riskier or less effective ones is an abandonment of common sense.
A Call for National Consistency
The American Society of Pain and Neuroscience (ASPN) and its partners have called for CMS to immediately withdraw the proposed LCDs (e.g., DL40267) and convene a Medicare Evidence Development & Coverage Advisory Committee to review the science and develop a unified, evidence-informed National Coverage Determination.
This is not a radical demand — it is a plea for standardization, for equity, and for integrity in the coverage process. A national policy would ensure that whether a patient lives in Kansas City or the Bronx, access to established, low-risk pain interventions would not depend on arbitrary MAC geography.
The Human Face of “Experimental”
Behind every coverage policy lies a patient. A veteran with post-knee replacement pain, a teacher with trigeminal neuralgia, a grandmother immobilized by osteoarthritis. They are the faces behind the data — people who have already failed conservative therapy and are desperate for relief. To call their best option “experimental” is not merely bureaucratic overreach; it is an act of cruelty disguised as caution.
Restoring Integrity to Pain Policy
CMS has a mandate to be both evidence-driven and patient-centered. It cannot claim the former while abandoning the latter. By disregarding professional consensus, violating statutory requirements, and fostering geographic inequity, the MACs have failed on both counts.
The path forward is clear: withdraw these flawed LCDs, reconsider the evidence transparently, and work collaboratively with pain specialists to craft rational, nationally consistent policy. If CMS truly seeks to reduce opioid dependence and promote value-based care, then preserving access to interventional pain options is not optional — it is essential.
Because pain does not discriminate by state lines. Neither should Medicare.
Dr. Hemant Kalia, MD, MPH, FIPP, FAAPMR, is a board-certified specialist in PM&R and pain management, renowned for his expertise in interventional spine care, cancer pain management, and advanced neuromodulation. As president and CEO of Savya Neuroscience Institute and president of the Center for Research and Innovation in Spine & Pain (C.R.I.S.P.), he leads innovative, patient-centered approaches to spine and pain treatment in Upstate New York, emphasizing education, research, and advocacy.
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