Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior horn medial meniscal tear, end-stage degenerative arthritis of patellofemoral joint, osteoarthritis. 
Treatment: Knee procedure ambulatory surgery (knee replacement for arthritis). 

The insurer denied coverage for knee procedure ambulatory surgery (knee replacement for arthritis). 

The denial is upheld. 

This is the case of a female with a medical history of right knee pain, anterior horn medial meniscal tear, end-stage degenerative arthritis of patellofemoral joint, osteoarthritis, multiple sclerosis and obesity. She has previously had a right knee arthroscopy with partial medial meniscectomy and left total knee arthroplasty. She has been followed by orthopedic surgeon and continues to have pain in her right knee. Her physician has recommended a right total knee replacement. The patient's body mass index (BMI) was 44.97. 

Morbid obesity is associated with increased complications after surgery. There is an increased rate of infection. There can be problems with exposure. There are commonly associated comorbidities which also increase the rate of post-surgical problems. Several national guidelines do not recommend surgery for people with a BMI over 35. The American Academy of Orthopedic Surgery (AAOS) recommends patients with morbid obesity (BMI of 40 or higher) take the following steps prior to undergoing elective orthopaedic surgery: 

- Discuss with their physician(s) and consider carefully the impact of their weight on possible complications and results after surgery. 

- Speak with their physician(s) about resources available to help them lose weight before surgery. A delay in surgery is not a judgmental statement, but rather a risk reduction tool to avoid potentially serious and life-changing complications. 

- If it is in the patient's best interest, consider delaying certain surgeries, such as joint replacement, where losing weight could improve the outcome of treatment, to provide time to take interventions for obesity. 

- Participate in a weight-loss program before undergoing TJA (total joint arthroplasty) or replacement. 

- Develop a plan to manage comorbidities. 

- Assess nutritional status and address any deficiencies. Patients with obesity have
a high incidence of altered nutritional status, and poor nutrition may contribute to comorbidities such as diabetes, in which blood sugar should be brought to reasonable levels to reduce risk. 

- Talk about rehabilitation protocols with their physicians and determine their ability and commitment level to follow them. 

- Consider signing a commitment letter to lose weight, to exercise and eat better to demonstrate responsibility for personal health. Even after surgery, patients must make an ongoing commitment to keep weight down for their overall health and for issues such as the longevity of TKAs (total knee arthroplasty). 

None of these recommendations were provided. Based upon the patient's current clinical condition, there was not sufficient evidence to support that knee procedure ambulatory surgery (knee replacement for arthritis) was considered medically necessary at this time.

The health plan acted reasonably, with sound clinical judgment and in the best interest of the patient. 

The insurer's denial of coverage for knee procedure ambulatory surgery (knee replacement for arthritis) is upheld. Medical necessity is not substantiated.