Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain.
Treatment: Arthroscopy (removal of the knee cartilage ) using endoscope.
The insurer denied the Arthroscopy (removal of the knee cartilage ) using endoscope.
The denial is upheld.

The patient is a female. She began with left knee pain after an injury with unknown mechanism. She recalls at work kneeling for several hours a day and got up and noticed pain. The patient underwent a few physical therapy visits. An intraarticular steroid injection was performed. X-ray of the left knee documented mild degenerative changes with medial joint space narrowing. MRI (magnetic resonance imaging) of the left knee documented lateral and medical meniscus tears with moderate medial and patellofemoral compartment arthritis with zones of full thickness cartilage loss and mild marginal ostoephytes consistent with moderate osteoarthritis. Office visit documented left knee pain with deep click, daily swelling and difficulty working due to pain. Examination documented tenderness over the medial joint line, Mcmurray positive for mechanical click with trace effusion.

Adverse determination with regards to health plan occurred as the procedure of knee arthroscopy with removal of knee cartilage was not supported "as the degree of arthritis was too advanced to support the requested service." Denial also occurred as records did not show that a 3 month trial of conservative treatment.

An appeal letter stated the patient underwent a left knee arthroscopy with medial and lateral meniscus debridement and chondroplasty performed after a failed lengthy course of conservative management with physical therapy, activity modification, over the counter medications and intra articular corticosteroid injections. The patient had examination findings consistent with medial meniscus tear. The patient did not have any preoperative osteophytes and only very subtle going space narrowing on imaging. Regarding conservative treatment, the patient underwent physical therapy and corticosteroid injection performed. Regarding physical examination findings, office visit documented tenders over medial joint line, positive patellar grind and Mcmurray for a mechanical click.

No, the requested health service is not medically necessary.
Regarding knee arthroscopy with arthritis and degenerative meniscus tears, literature recommends a "formal course of non-steroidal anti-inflammatory drugs (NSAIDs) (if tolerated), rest, ice, weight loss and supervised, structured physical therapy for 3-6 months has been shown to do well for a large portion of patients with degenerative meniscus tears. This applies strongly to patients with moderate to severe osteoarthritis who can do quite well with therapy as a method to delay arthroplasty." The patient completed only a few physical therapy visits according to available medical records. This occurred greater than 1.5 years prior to surgical treatment. An intraarticular steroid injection was performed, again, greater than 1.5 years prior to surgical treatment. (1)

With regards to appeal that the patient does not have Kellgren Lawrence 2 degenerative changes, X-ray of the left knee documented mild degenerative changes with medial joint space narrowing. MRI (magnetic resonance imaging) of the left knee documented lateral and medical meniscus tears with moderate medial and patellofemoral compartment arthritis with zones of full thickness cartilage loss and mild marginal ostoephytes. Kellgren Lawrence is documented as grade 2 (minimal) if definite osteophytes and possible joint space narrowing are present. The x-rays and MRI (magnetic resonance imaging) in the available medical records document medial joint space narrowing with osteophytes. This would be classified as Kellgren Lawrence 2. According generally accepted guidelines, this surgery is not supported for Kellgren Lawrence 2 or greater.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Guidelines do not support knee arthroscopy with cartilage debridement for Kellgren Lawrence 2 or higher arthritis.  Further, physical therapy and steroid injection occurred prior to 1.5 years prior to surgical treatment.