Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 55-year-old female who had a slip and fall injury in June 2015 followed by right knee meniscus surgery on 9/01/15. On 11/14/16, right knee magnetic resonance imaging (MRI) documented mild diminutive changes of the mid-zone and posterior horn of the medial meniscus with blunting of the free edge, mild subluxation of the weight bearing articular surface, and increased signal likely related to prior partial meniscectomy and fibrovascular scarring tissue. There was mild tricompartmental marginal osteophytosis with near full thickness hyaline cartilage loss of the medial knee compartment. There was small joint effusion without loose body. On 11/14/16, the records noted right knee pain. Conservative treatment had included corticosteroid injection in June 2016 with no relief, and hyaluronic acid injection in June 2016 with 50% relief for two to three months. She reported a significant flare-up of symptoms with hiking and walking stairs while traveling in September 2016. She had been diagnosed with osteoarthritis, and a total knee replacement had been recommended. She was being seen for a second opinion. Right knee examination documented active range of motion -2 to 125 degrees, medial joint line pain, and significant limp. X-rays of the knee demonstrated severe medial joint space narrowing. MRI was reviewed and showed medial osteoarthrosis, loss of the medial meniscus, and chondral loss. The diagnosis was right medial knee osteoarthrosis. The treatment plan recommended right medial unicondylar knee replacement. On 1/10/17, the patient underwent medial compartment partial knee replacement using the MAKO procedure. The Health Insurer has denied reimbursement for medial compartment partial knee replacement performed on 1/10/17. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Nationally recognized evidence based medical guidelines state that knee joint replacement is well-accepted as a reliable and suitable surgical procedure to return highly symptomatic patients to better function. If only one knee compartment is affected, a unicompartmental or partial replacement may be considered. Indications for surgery include failure of conservative treatment, including exercise therapy and medications, subjective findings of stiffness, nighttime joint pain, minimal pain relief with conservative care, current significant functional limitations, age over 50 years, body mass index less than 40, and x-ray findings of significant osteoarthritis. Current peer-reviewed literature supports unicompartmental knee replacement as an effective treatment for end-stage, symptomatic unicompartmental osteoarthritis of the knee, particularly in patients younger than 65 years. This patient presented with persistent right knee pain, mild at rest and moderately severe with activity. She was status post prior medial meniscectomy in 9/01/15 with multiple flare-ups noted in the postoperative period. Functional limitations were noted in activities of daily living due to pain. Clinical examination findings were consistent with reported x-ray evidence of severe medial joint space narrowing. Reasonable and/or comprehensive conservative treatment had been tried, with inadequate relief of pain. Given the patients age, severity of medial compartment osteoarthritis, and limitations in her daily activities, the medial compartment partial knee replacement performed on 1/10/17 was consistent with evidence-based medical guidelines and peer-reviewed literature. Therefore, medial compartment partial knee replacement performed on 1/10/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.