Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Right knee pain.
Treatment:  Arthroscopy of the right knee meniscectomy.

The insurer denied the Arthroscopy of the right knee meniscectomy.  The denial is overturned.

This adult male had issues associated with right knee pain.  Services, described as arthroscopy of the right knee meniscectomy, were provided.  The services were felt to be not medically necessary by the health plan, stating that the tear of the cartilage was not detailed as causing blocked range of motion, weakness, buckling, or locking with associated knee pain.  

The magnetic resonance (MR) imaging of the knee describes a horizontal undersurface tear posterior horn medial meniscus with mild to moderate osteoarthritis with a synovial cyst in the posterior capsule.  A cortisone injection was of no clear benefit with pain over the medial side with activity, climbing, bending, going up and down stairs, or kneeling with pain.  Clinical exam noted a body mass index of 27.7.  The patient's range of motion was zero degrees / 120 degrees, equal to passive motion.  Lachman test was negative; however, there was a positive Murray's test with joint line pain. Surgery was discussed given the large medial meniscus tear present without benefit of cortisone.  

In follow-up, pre-surgery described the knee was with ongoing pain and achiness with sleeping.  In addition, it stated that" The knee does not want to move sometimes."  With a clinical exam unchanged, positive effusion, magnetic resonance image scan positive for medial meniscus resection, arthroscopy was requested.  The surgical note from the Provider described arthroscopy of the knee with medial meniscectomy.  History was described as pain with activity and ability to use the knee with magnetic resonance image consistent with the diagnosis of a medial meniscus tear.  Surgery was undertaken noting the large posterior horn posterior body tear of the medial meniscus, which was resected.  Anterior and posterior cruciate ligaments were found to be intact.  

The proposed treatment is considered medically necessary. 

The clinical guidelines, knee surgery, arthroscopic and open procedures for meniscectomy, describe the medical necessity to be functionally limiting pain including pain in one of the following: 1. The range of motion is blocked due to pain, 2. Evidence of joint swelling/effusion, or 3. Joint line tenderness, and also positive Murray test, Thessaly test or Apley's compression test.  There should be failure of provider directed nonsurgical management for least three months.  It is noted that an acute meniscal tear associated with functional limiting pain and locking on physical exam does not require a three month period of provider directed nonsurgical management.  In addition, there should be magnetic resonance imaging/computed tomography imaging that demonstrates the changes that are consistent with the findings of a meniscal tear.  Medical necessity would be established for meniscectomy and debridement if the criteria have been established along with a change in symptoms that include new mechanical symptoms in the absence of underlying degenerative changes.

What was noted within the operative note was that there was an absence of any significant degenerative changes with a large posterior horn body tear of the medial meniscus.  There was a history of pain with activity and inability to use anything because of this degree of pain.  Pre-operative assessment had described positive Murray test, joint effusion, and tenderness over the medial joint line.  The Provider described that the cortisone injection was not of any clear benefit.  Persisting pain was noted.  Pain was noted with climbing, bending, using stairs and kneeling consistent with the medical necessity considerations.  Magnetic resonance imaging did not show evidence of significant disease process.  Therefore meniscectomy was considered appropriate for the proposed treatment of the knee condition; it was medically necessary.