Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee problem/pain
Treatment: Shaving of knee joint cartilage
The health plan denied: Shaving of knee joint cartilage
The determination is: Upheld

The patient is a female who was diagnosed with right knee patella chondromalacia. This is a request for shaving of knee joint cartilage. The request was previously denied due to insufficient magnetic resonance imaging (MRI) findings consistent with chondral damage. The right knee x-ray report showed degenerative changes without evidence of acute osseous pathology. There was mild narrowing of the medial femoral tibial compartment. A right knee MRI report documented prominent arthritic change in the patellofemoral articulation with a small joint effusion and a medial retro patellar plica. The patient reported right knee pain despite many years of conservative treatment, including injections and therapy. There was persistent anterior pain. The body mass index (BMI) was 24.44. The comorbidities included insomnia. No pertinent surgical history was reported. Objectively, there was peripatellar tenderness, crepitus with range of motion, and lateral patellar tracking. The provider recommended a right knee arthroscopy with patellofemoral chondroplasty and lateral patellar release. A clinical note stated that the symptoms were impacting activities of daily living. The operative report stated that a right knee arthroscopy with lateral release and patellofemoral chondroplasty was performed. The intraoperative findings stated that there was grade 4 chondral changes on the trochlea and undersurface of the patella with lateral patella tilt and maltracking. A chondroplasty was therefore performed in this area with debridement of chondral fragments. A lateral release was also performed.
At issue is the medical necessity of shaving of the knee joint cartilage.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of shaving of knee joint cartilage was not medically necessary for this patient. The request was previously recommended for non-certification due to insufficient MRI findings consistent with chondral damage. The MRI for the right knee documented prominent arthritic change in the patellofemoral articulation, which does not meet the plan criteria. The article cited from the World Journal of Clinical Cases concluded that debridement can significantly reduce the knee resting pain and knee functional status of patients with Kellgren-Lawrence grades 1-3 within 2 years after treatment. Another article concluded that over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function. In this case, the MRI was consistent with prominent arthritic change in the patellofemoral articulation. Intraoperatively, there was note of grade 4 chondral changes in the patellofemoral compartment on both the trochlea and patella. There is insufficient medical literature to support a chondroplasty for grade 4 arthritic changes. As such, the requested health service/treatment of shaving of knee joint cartilage was not medically necessary for this patient.