Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total left knee arthroplasty to be performed using computer-assisted musculoskeletal surgical navigation system. Current medical literature does not support the routine use of computer-assisted navigated total knee arthroplasty (TKA) over conventional TKA as to ultimate clinical outcomes of functional improvement and pain reduction. In a randomized, controlled trial at five years, Young and colleagues reported, We found no mid-term functional or radiographic differences between TKAs with mechanical alignment or kinematic alignment. The anticipated improvements in patient-reported outcomes with kinematic alignment were not realized. Because kinematic alignment results in a high proportion of patients whose tibial components are inserted in varus, loosening remains a potential long-term concern. Given the unknown impact on long-term survivorship of the substantial alignment alterations with kinematic alignment, our findings do not support the routine use of kinematic alignment outside of a research setting. Lee and colleagues concluded, There were no significant differences in clinical or radiological outcomes between computer-navigated TKA and conventional TKA. It remains unclear which TKA technique yields better results in terms of mid- to long-term clinical and radiological outcomes. In this case, the patient presented to her provider on 1/25/21 and reported bilateral knee pain, with the left knee more symptomatic than the right. An examination noted moderate, generalized tenderness  about the lateral and medial aspect and over the patellofemoral joint. There was bilateral mild swelling and crepitus. The left knee was noted to have range of motion of five to 120 degrees, and anterior patellar grind test, Apleys test, McMurray test, and patellar grind tests were positive. The current scientific evidence does not support the use of computer-assisted navigation as more beneficial than standard TKA without navigation. Therefore, total left knee arthroplasty to be performed using computer-assisted musculoskeletal surgical navigation system is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested total left knee arthroplasty to be performed using computer-assisted musculoskeletal surgical navigation system is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts 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.