Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Computerized tomography (CT) of the knee.

The insurer denied coverage for computerized tomography (CT) of the knee.  The denial is overturned.

This case involves an adult female diagnosed with unilateral primary osteoarthritis of the right knee who is being recommended for computed tomography (CT) lower extremity without contrast material for treatment planning. The patient was being considered for Mako (robotic surgery) of the right knee to treat osteoarthritis.  A bone scan indicated the patient had age-related osteoporosis without current pathological fracture and osseointegration failure of dental implant, due to poor bone quality.  The patient obtained a CT of the right knee, noting moderate to severe osteoarthritis affecting the medial femorotibial and patellofemoral compartments with moderate to severe joint space narrowing.  There was subchondral cystic change seen of the patella with joint effusion elicited and decompressing into a popliteal cyst with the latter containing ossific loose bodies.  X-rays were obtained on the same date noting moderate to severe osteoarthritis of the medial femorotibial and patellofemoral compartments of the right knee with possible bone-on-bone contact involving the patellofemoral compartment and right knee joint effusion elicited.  The patient presented for preoperative medical evaluation for right replacement total knee computer-assisted navigation Stryker triathlon cemented Cruciate Retaining (CR). This review pertains to the denial of coverage for radiology services.  The patient was denied coverage for the CT scan of the knee with claims that the physician planned to use the Mako technique for the patient's joint replacement surgery.  The physician ordered a CT scan of the knee in preparation for surgery to help guide the Mako procedure.  Because the Mako technique for joint replacement has not been approved for coverage by the health plan, the subsequent CT of the knee to plan for surgery was also not medically necessary.  The patient submitted an appeal stating that a CT scan of the right knee prior to the Mako technique enables a knee replacement to be more precise/accurate.  The patient claimed to have an easier recovery with long-term benefits having included reduced medical expenses.  This review pertains to the denial of coverage for radiology services consisting of the CT scan of the right knee.

Literature states that CT scans were found to better detect medial and lateral arthritic changes, bony deformities, subchondral cysts, and cartilage losses. CT scans were shown to 99% accurately predict prosthetic sizes preoperatively. CT scans can also help better visualize surrounding anatomy, such as the posterior cruciate ligament, and have therefore been linked to better soft tissue protection during total knee arthroplasty. Although radiation is a potential concern, newer imaging protocols have comparable exposure to plain radiographs. Compared with plain radiographs, CT scans were found to be more accurate and provide more clinically relevant data.  The patient had evidence of moderate to severe osteoarthritis affecting the right knee.  She needed knee replacement surgery, and despite the physician recommending the Mako technique for the procedure, the recommendation for a CT scan for preoperative planning is within the standard of care.  A CT scan does provide more accurate information than a traditional radiograph and can help to direct the surgery more effectively.  As such, the radiology services were considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for radiology service(s) is substantiated.