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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MAKOplasty knee surgery for treatment of the enrollees knee pain status post left knee arthroplasty.  Findings:  The physician reviewer found that MAKOplasty is a robotic assisted system to help the surgeon improve the alignment of unicompartmental and total knee arthroplasties. A review of the literature indicates no superiority with regard to the functional outcome with MAKOplasty compared to a standard unicompartmental or total knee arthroplasty. Although the robotic systems can help improve lower leg alignment, component positioning and soft tissue balancing, studies have shown no functional superiority in outcomes compared to conventional unicompartmental or total knee arthroplasties. The study by Blyth and colleagues concluded that robotic arm-assisted surgery results in improved early pain scores and early function scores in some patient reported outcomes measures, but no difference was observed at one year post-operatively between the robotic arm-assisted and conventional procedures. Similarly, the review by van der List and colleagues also does not indicate any superiority with regard to functional outcome with the robotic arm-assisted arthroplasty. In light of the foregoing, MAKOplasty has not been established as superior to conventional unicompartmental or total knee arthroplasty in the peer-reviewed literature. Concerning the bicompartmental knee replacement, the literature recommends a total knee arthroplasty instead due to inconsistent pain relief with the bicompartmental arthroplasty and a significantly higher complication rate. As such, the request for MAKOplasty knee surgery is not likely be more beneficial for the treatment of the patients medical condition than standard cold packs. Final Result: Two of three reviewers determined that the requested surgery 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 reviewer number one is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.Physician reviewer number two is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.Physician reviewer number three is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.