Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a knee replacement surgery. The submitted documentation does not support the medical necessity of the requested service. In a study of the appropriateness of total knee arthroplasties (TKA) in the United States, Riddle and colleagues found that the risk/benefit for TKA favored patients with intense or severe symptoms of knee osteoarthritis, who were at least 55 years old, had limited mobility, and had a body mass index (BMI) under 40 kg/m2. The authors noted that outcomes were much less favorable for patients with slight or moderate symptoms and functional loss, making the procedure not appropriate. Ferket and colleagues reported that the current practice of TKA in a recent U.S. cohort of patients with knee osteoarthritis had minimal effects on quality of life and quality adjusted life years. Fucentese noted, The main aims of surgery are to reduce pain, increase mobility and quality of life. In order to qualify for total knee arthroplasty (TKA) patients must fulfil major and minor criteria; however, after TKA approximately one fifth of patients are not satisfied with the result. In order to reduce this rate, indications should be narrowly set and expectations should be thoroughly discussed with the patient prior to an intervention. The high degree of dissatisfaction must be improved by intensifying efforts in further research. Klit reported in a prospective multicenter study, Overall, TKA did not affect the patients socioeconomic status, and overall, patients did not experience impairment of sexual life, but decreased frequency and negative affection of sexual practice should be anticipated. Alternative outcome measurements of TKA surgery not focusing on implants and surgical techniques shed new light on important consequences of arthroplasty surgery. Gunaratne reported that dissatisfaction following TKA is common and pertained to several key factors, including patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery. Kahlenberg note that the majority of studies reporting patient satisfaction after total knee replacement represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies used validated satisfaction instruments. In this case, the patient has a diagnosis of left knee arthritis and persistent pain. The records do not document a recent trial and failure of less invasive conservative care measures, such as recent physical therapy or injections. The notes indicate that physical therapy for the knee was tried in 2015. Regarding steroid injections, it appears that these may have been done in 2017. There is no clear documentation of the outcome from any injections that may have been provided, such as improvement in pain and function, and duration of effect. Additionally, there is no indication that there been a trial and failure of viscosupplementation. Given the medial and lateral compartment arthrosis, it is reasonable to consider this as an alternative to an extensive surgical procedure. In this clinical setting, the requested service is not medically indicated. Therefore, the request for left knee replacement surgery is not medically reasonable or necessary.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.