Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee arthritis
Treatment: Left Total Knee Arthroplasty
The insurer denied Left Total Knee Arthroplasty.
The health plan's determination is overturned. 

The patient is a female diagnosed with bilateral knee arthritis who presented in follow-up regarding her left knee. She previously underwent aspiration and was denied surgery as she had not completed therapy. The patient went to physical therapy and was not able to tolerate treatment due to increased pain. Following physical therapy sessions, she was not able to complete activities for 2 days.
She has persistent effusions and a comorbid history of rheumatoid arthritis. An exam of her left knee documented effusion, with documented motion of 20-85 degrees as well as global tenderness. The provider stated that the patient has not tolerated physical therapy and does not recommend continued aspirations. A progress note documented that the patient was canceled for a left knee arthroplasty as there was not a failure of 6 weeks of physical therapy. The patient complained of swelling and effusion which limited knee motion. She has severe arthritis and is not able to tolerate physical therapy. She stated that outpatient therapy was completed for the left knee in the years prior. She was provided with knee aspiration and was recommended to appeal for surgery.
She is not able to walk long distances. She has failed anti-inflammatories, cortisone injection, hyaluronic acid injection, ice, physical therapy, weight loss, and ambulatory aids. An exam of her left knee documented diffuse swelling, mild effusion, varus deformity, tenderness, range of motion of 5-115 degrees, crepitus, and a popliteal cyst. A progress note documented that x-rays of the left knee demonstrate medial joint space narrowing, sclerosis, osteophytes, patellofemoral joint space narrowing, and varus alignment.
The provider reviewed a home exercise program, which the patient had been attempting, but her symptoms were worsening. The provider stated that the patient was not able to progress with further activities due to severe pain and an inability to fully extend her knee. They stated that physical therapy is not a feasible plan for treatment.
At issue is the medical necessity of the Left Total Knee Arthroplasty.

The requested health service/treatment of Left Total Knee Arthroplasty is medically necessary for this patient.
Knee arthroplasty is supported for end-stage knee arthritis not improved with initial conservative treatments. In this circumstance, the patient has symptomatic left knee arthritis with significantly reduced function that was not improved with anti-inflammatories, cortisone injection, hyaluronic acid injection, physical therapy, weight loss, and ambulatory aids.
On exam the patient has significantly reduced motion of 20-85 (degree) with global tenderness and effusion. She has not been able to participate in physical therapy due to significant deficits and severe pain and it is noted that physical therapy is not a feasible treatment plan. X-rays of the knee document varus deformity with joint space narrowing, sclerosis, and osteophytes. The provider has recommended arthroplasty. Given the end-stage arthritis with significant pain and functional limitations not improved with all available conservative treatments, progression to arthroplasty is medically necessary.