Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee replacement revision surgery using a different type of knee joint to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the requested OON knee surgery. You say that you have not been able to find a network provider who is willing to provide you with another surgical intervention. You state these providers only want to continue with conservative measures. You found a provider OON who says that there is a surgical option that could help you, and you feel that you should be allowed OON care since no network providers are willing to provide surgery. The Plan denied your request. The Plan says the documentation does not show that the requested surgery from the OON is medically reasonable and necessary.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested OON knee surgery. Our reviewer says that the requested type of procedure is not shown to be medically reasonable and necessary and, therefore, there is no medical need for the enrollee to be treated by an OON provider. Our physician reviewer found the enrollee is a female with a diagnosis of chronic right knee pain after a previous total knee arthroplasty (TKA). An in-network provider documented stability of the replacement construct, with knee hypersensitivity. There was documented constant pain in the knee worse with activity, swelling and 0-120 degrees range of motion of the right knee. Right knee x-rays demonstrate well-fixed total knee components with no evidence of migration or loosening. There was a consideration for knee desensitization therapy, among other non-surgical treatments. (The enrollee had sought second opinion consultations with multiple orthopedists within the medical group.)

The enrollee then went outside of the network and was evaluated by an orthopedist who agreed to do surgery on the enrollee. On that OON provider's consult, the knee construct was noted to be relatively tight on the basis of a retained posterior cruciate ligament (PCL) and considered the individual for revision knee replacement. The enrollee was then reevaluated by her provider within the medical group who concurred that the surgery would be appropriate.

It does not appear to be reasonable and necessary for this surgery to be provided by the OON surgeon based on the subjective complaints and clinical/imaging findings overall. There is no significant evidence of loosening, infection, or instability. There are no significant functional range of motion issues. In addition, the knee has been noted to be hypersensitive with an indication for desensitization therapy (among other non-surgical treatments). Overall, the significant risks of the proposed OON procedure outweigh any potential benefits. Medical reasonableness and necessity have not been established in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested OON knee surgery have not been met.

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested OON knee surgery. Therefore, we decided that the Plan does not have to pre-approve a knee replacement revision surgery using a different type of knee joint to be provided by an out of network (OON) provider.