Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic right knee anterior cruciate ligament (ACL) tear, Right knee medial and lateral meniscal tears (chronic versus acute)

Treatment: Magnetic resonance imaging (MRI) of the knee (CPT code 73721).

The insurer denied coverage for magnetic resonance imaging (MRI) of the knee (CPT code 73721).

The denial is upheld. 

This is a male patient with a history of chronic right knee anterior cruciate ligament (ACL) tear and right knee medial and lateral meniscal tears (chronic versus acute). Electromagnetic radiation (x-ray) tests of the right knee were done and the impression was joint space narrowing medial compartment right knee with small joint effusions. The patient's initial magnetic resonance imaging (MRI) revealed ACL tear with associated bone bruise in the lateral femoral condyle; complex tear involving the posterior horn of the medial meniscus including longitudinal and horizontal components; likely longitudinal tear of the posterior horn of the lateral meniscus; small joint effusion. The patient underwent surgical repair: ACL reconstruction and partial medial and lateral meniscectomies done by an orthopedic surgeon. The patient was seen for a follow-up visit and the plan was for weight-bearing as tolerated with a brace and physical therapy.  The patient was seen again and reported improvement; he continued in physical therapy.  A few months after, the patient reported a hyperextension injury to the right knee in a friend's backyard with resultant deep knee pain, which was improving but not resolved.  X-ray tests of the right knee were done and showed mild degenerative changes and postoperative changes. The orthopedic surgeon ordered a follow-up MRI of the right knee to evaluate the patient's ACL graft's integrity and ensure that it was not ruptured.

As per literature, MRI is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI should be recommended if conservative treatment has not been beneficial, and the diagnosis can alter the decision, prognosis and plan of care, such as assessing the medical necessity for more invasive procedures (surgical treatment). Thus, the performance of the MRI should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary. According to UpToDate on meniscal injury of the knee, a presumptive diagnosis of meniscal tear can be based upon the mechanism of injury in the case of acute tears (often involving twisting the knee while the foot is planted), characteristic symptoms, such as mechanical catching or locking, and corroborating signs from the physical examination, including joint line tenderness and positive provocative tests (e.g., McMurray, Thessaly). MRI is not necessary if non-operative management can be successful. 

Based on the medical records, the patient incurred an injury after recent surgery. The patient was seen by his physician and had limited findings on physical examination, i.e. no swelling, no tenderness, normal motion and a "firm endpoint". The patient was recommended MRI upon initial consultation of this new injury. There was no clinical correlation for graft disruption. There was no indication that another operation was planned. The patient did not receive non-operative management or treatment (i.e. ambulatory support, recommendation to avoid running and continue physical therapy). Thus, there is insufficient clinical support that the follow-up MRI is medically indicated at this time.

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

The carrier's denial of coverage for magnetic resonance imaging (MRI) of the knee (CPT code 73721) should be upheld. The medical necessity is not substantiated.