Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Joint Problem/pain
Treatment: Surgical Services
The health plan denied the proposed surgery as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

This is a patient who has been recommended for left knee arthroscopic partial meniscectomy.
A left knee x-ray radiology report reveals only arthritic changes involving the patella and patellofemoral joint space along with early patellar tendinopathy.
A progress note reveals presentation for evaluation of a left knee problem that began two weeks prior to presentation. The symptoms have worsened recently. The use of naproxen helps a little bit. The current pain is rated at 7/10. The physical examination of the left knee reveals range of motion from 10-40, painful beyond that, grade one effusion, no instability, and medial greater than lateral tenderness. The provider indicates x-rays show mild arthritic changes. There is a recommendation for a magnetic resonance imaging (MRI) scan. Tramadol was prescribed.
The MRI report reveals a nondisplaced medial meniscus tear, tricompartmental osteoarthritis, mild semimembranosus bursitis, small joint effusion, mild synovitis, and small posterior extra-articular ganglion cyst. Regarding the osteoarthritis, and the medial compartment there is mild to moderate osteoarthritis with joint space narrowing, marginal osteophytes, and cartilage thinning. In the lateral compartment, there are small osteophytes with low-grade chondromalacia. The patellofemoral compartment, there is moderate osteoarthritis with joint space narrowing, small osteophytes, and high-grade chondromalacia of the patella and trochlea. Follow-up progress note of left knee problem. The patient continues to have medial-sided sharp, jabbing pain. There is persistent swelling and decreased range of motion. The pain is rated at 7/10. The physical examination of the right knee reveals range of motion from 0-100, pain beyond that, grade one effusion, and medial joint line tenderness. The provider indicates a left knee MRI scan was reviewed, and it shows mild arthritis as well as a medial meniscus tear. There is also a small posterior extra-articular ganglion cyst. The provider indicates options: they could try physical therapy, giving it time, or arthroscopy. The patient elected to proceed with arthroscopic surgery. The provider reports the anticipated surgery is removal of the medial meniscus of the left knee, not both cartilages. They do not use an endoscope, using arthroscope. They conclude that it is their opinion that an arthroscopic evaluation of the knee using arthroscope to evaluate the meniscus of the knee is indicated.

The requested joint surgery is not medically necessary for this patient. The provided documentation indicates the patient has left knee pain that persist despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). There are physical examination findings consistent with a meniscus tear. Imaging findings include joint space narrowing and osteophyte formation consistent with Kellgren-Lawrence (K-L) grade 2 or higher. An MRI shows a nondisplaced medial meniscus tear in the setting of mild-to-moderate medial compartment osteoarthritis. There are no documented mechanical symptoms, and there is no evidence of a failure with physical therapy. The provider states they discussed trying to treat the meniscus tear with physical therapy or arthroscopic surgery, and the patient elected to proceed with arthroscopic surgery.
As noted in the 2018 referenced article from Arthroscopy, there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy for the treatment of meniscus tears in the setting of degenerative disease. Given the lack of failure of physical therapy and lack of significant mechanical symptoms that may support surgery without physical therapy, the requested partial meniscectomy is not medically necessary for this patient.