Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Pain.
Treatment: Knee Surgery.
The insurer denied Knee Surgery.
The determination is overturned.

This is a patient who has been recommended for left knee core decompression and the use of bone marrow aspirate concentrate. A left knee x-ray radiology report indicates that since prior x-rays, there has been persistent sclerosis within the medial femoral condyle and medial tibial plateau and metaphysis corresponding to areas of avascular necrosis that were noted on a previous magnetic resonance imaging (MRI) scan. A progress note indicates that the patient presented with avascular necrosis of the left knee medial femoral condyle and a small area of proximal medial tibial. The patient developed knee pain without trauma or injury. The patient was unable to bear weight due to pain. The patient has been doing physical therapy since. The pain did not improve, the pain started worsening. There is pain on and off with weight-bearing. The patient has been using crutches. The symptoms are worse at the end of the day. The patient rates the pain at 7/10. The left knee examination indicates there is tenderness to palpation of the medial femoral joint line and distal medial femur, tenderness to palpation of a lesser extent over the medial tibia, small effusion, and passive range of motion from 3-120 degrees (). There is an indication that an MRI of the left knee showed edematous osteonecrosis of the medial femoral condyle with a subtle step off at the posterior articular surface suggesting subchondral fracture and a follow-up MRI showed unchanged findings of osteonecrosis involving the medial femoral condyle, medial tibial plateau, and posterior lateral condyle. The impression is left knee osteonecrosis likely secondary to systemic lupus erythematosus. The provider states that due to significant pain and a risk of collapse requiring joint replacement surgery, they feel the best treatment option is surgical core decompression and the use of bone marrow aspirate concentrate. At issue is the medical necessity of the requested knee surgery.

Yes. The requested knee surgery is medically necessary.
The provided documentation indicates that the patient developed left knee pain of insidious onset with the inability to bear weight due to pain. The patient has persistent pain despite nonoperative treatment. There are X-ray and MRI findings of osteonecrosis of the medial femoral condyle, medial tibial plateau, and posterior lateral condyle. The provider has recommended surgical core decompression and the use of bone marrow aspirate concentrate. As noted in the referenced articles from International Orthopedics, the Journal of Clinical Medicine, and the Journal of Arthroplasty, joint preserving surgery with core decompression and bone marrow aspirate concentrate is a supported treatment for the treatment of osteonecrosis of the knee. Given the osteoporosis of the knee, joint preserving surgery with core decompression and bone marrow aspirate concentrate is clinically appropriate and considered effective for the patient's condition, is required for the direct care and treatment of the condition, and is provided by generally accepted standards of medical practice. The patient's condition will be adversely affected if the services are not provided, and without this surgery, the osteonecrosis can progress, which would require treatment with total knee arthroplasty, which would not be prudent. Based on the available information, the requested health service/treatment of knee surgery is medically necessary for the station.