Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior cruciate ligament tear
Treatment: Outpatient Surgery on the Knee-Meniscus (29882 x1, 29881 x1)
The insurer denied outpatient surgery on the knee-meniscus (29882 x1, 29881 x1).
The determination is overturned.

The patient injured his right knee. A pre-operative magnetic resonance imaging (MRI) scan confirmed a torn anterior cruciate ligament. The patient had persistent right knee instability and opted to undergo anterior cruciate ligament (ACL) reconstruction surgery with bone patella bone autograft. The surgeon noted intra-operatively that the patient had torn both his medial and lateral menisci in addition to the ACL. The patient underwent ACL reconstruction with bone patella bone autograft (CPT [Current Procedural Terminology] 29888) as well as medial meniscus repair (CPT 29882) and partial lateral meniscectomy (CPT 29881). The health plan denied the medial meniscus repair (CPT 29882) and the partial lateral meniscectomy (CPT 29881). The rationale for this denial was that the pre-operative imaging did not confirm the meniscal pathology. At issue in this case is the medical necessity of the medial meniscal repair and partial lateral meniscectomy that were performed for this patient.

The medical records contain an operative report in which a red-red zone medial meniscus tear is documented, as well as an inner rim posterior horn lateral meniscus tear. The surgeon performed a medial meniscus repair (CPT 29882) and a partial lateral meniscectomy (CPT 29881), in addition to the ACL reconstruction (CPT 29888). The medial and lateral meniscus tears were not identified on the preoperative MRI scan of this patient's right knee. The medial meniscus repair and partial lateral meniscectomy procedures were denied because the MRI did not confirm the meniscal pathology. The medical necessity of these procedures, however, is established based on the documentation in the operative report. Furthermore, the current, peer-reviewed literature, including an article published by Dufka and colleagues in the Knee Journal, concluded that "This study demonstrates only moderate sensitivity and specificity of pre-operative MRI in the detection of meniscus tears requiring operative treatment in the setting of ACL injury. High rates of false diagnoses were observed, suggesting MRI may not be as accurate in predicting positive or negative meniscus findings at the time of ACL reconstruction as previously reported." Thus, the medial and lateral meniscus tears identified intraoperatively mandated treatment in this active, young male patient.

Based the operative report in the provided medical records, this young patient sustained injuries to the medial and lateral meniscus of his right knee that were unrecognized on the pre-operative MRI scan. A recent article published by Munger and colleagues in the Journal of Pediatric Orthopedics concluded that "In this ACL-deficient pediatric and adolescent cohort, there were 26 (24.3%) patients with unrecognized meniscal injuries. A vertical tear in the posterior horn was the most commonly unrecognized meniscal injury, supporting the findings of prior research postulating that the location and configuration of a tear influence the accuracy of MRI in detecting these injuries. More research is needed to investigate strategies to improve the detection of meniscal tears in pediatric and adolescent patients preoperatively. These findings have implications with regard to patient counseling, operative planning, anticipatory guidance with regard to postoperative rehabilitation, recovery expectations, and surgical outcomes."

An article published by Pike and associates in the Journal of the American Academy of Orthopedic Surgeons supports the care rendered for the medial and lateral meniscus tears identified intra-operatively in this patient's right knee. Therefore, the medical necessity of the medial meniscus repair (CPT 29882) and partial lateral meniscectomy (CPT 29881) is supported.