Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee injury.
Treatment: Joint Surgery (right knee arthroscopy) Pre-service.
The insurer denied the Joint Surgery (right knee arthroscopy) Pre-service. 
The denial is upheld. 

The patient is a male. He sustained injury to his right knee. He twisted his knee. He reported difficulty with activities and had received several conservative treatments. His condition did not improve, and evaluation was completed. His physical examination was significant for medial tenderness and grinding/loading to patella femoral compartment. His physician opined occult meniscal tear vs. (versus) unstable cartilage vs. capsular injury. He recommended arthroscopic surgery.

No, the proposed surgery is not medically necessary.

The records were inconsistent to substantiate necessity of surgery. Several diagnoses have been presented, i.e. (that is), Possible meniscal tear.

There is documentation that the patient has subjective weakness, joint line tenderness, and test failure of provider-directed non-surgical management for at least three (3) months in duration. However, the patient's knee range of motion is not "blocked" due to pain; his knee is not documented to be giving way; he is not experiencing buckling of the knee; he is not experiencing painful locking, clicking, catching, or popping during weight-bearing; he does not have limited range of motion; joint swelling/effusion is not evidenced; he does not have Positive McMurray's Test, Thessaly Test, or Apley's Compression; the MRI (magnetic resonance imaging) did not show evidence of meniscal tear; and there is no evidence of anterior knee pain, as the patient's pain is medial.

Therefore, given the above, the patient does not meet Evicore guidelines, and there is no indication for arthroscopic surgery at this time. The Evicore Guidelines are consistent with the standard of care within the practicing medical community. Therefore, the surgery is not medically necessary.

The Evicore Guidelines criteria are as follows:
      -Meniscectomy or Meniscal Repair
           -Meniscectomy (partial or total) or meniscal repair is considered medically  necessary when ALL of the following criteria have been met:
               1) Function-limiting pain (e.g. (example), loss of knee function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment). Individual reports pain and any ONE of the following mechanical symptoms: (1) Knee range of motion is "blocked" due to pain, NOT MET. (2) Giving way, NOT MET. (3) Subjective weakness, MET. (4) Buckling of the knee NOT MET. (5) Painful locking, clicking, catching, or popping during weight-bearing activities NOT MET.
               2) TWO OR MORE of the following physical examination findings: (1) Limited range of motion, NOT MET. (2) Evidence of joint swelling/effusion, NOT MET
Joint line tenderness,  MET.  (3) Positive McMurray's Test, Thessaly Test, or Apley's Compression, NOT MET. (4) Test Failure of provider-directed non-surgical management for at least three months in duration, MET. (Please note: Acute meniscal tear with associated function-limiting pain or locked knee does not require three months of provider-directed non-surgical management).
               3) MRI (magnetic resonance imaging) or CT (computed tomography) arthrogram demonstrates a meniscal tear that extends to the articular surface (not simply degenerative changes, i.e., fraying) that correlates with the individual's reported symptoms and physical exam findings. NOT MET, as the MRI (magnetic resonance imaging) did not show evidence of meniscal tear.

Possible medial collateral ligament injury. NONE met as a reconstruction is not planned.

For possible patella femoral disorder (noted evidence of disease on MRI [magnetic resonance imaging]), the applicable criteria are as follows:
      - Procedures for Patellofemoral Conditions. 
            - Procedures for anterior knee pain (i.e., Fulkerson or Maquet type procedures) are considered medically necessary when ALL of the following criteria have been met:
               1) Function-limiting anterior knee pain (e.g., loss of knee function which interferes with the ability to carry out age appropriate activities of daily living and/or demands of employment)
               2) Any ONE of the following physical examination findings:(1) Joint effusion. (2) Tenderness of the medial or lateral facets. (3) Positive Patellar Grind Test. 
               3) Failure of provider-directed non-surgical management for at least three months in duration. 
               4) Confirmed osteochondral defect of the patellofemoral joint (MRI [magnetic resonance imaging], CT [computed tomography] scan, or previous arthroscopic procedure).

NONE MET. There is no evidence of anterior knee pain. The patient's pain is medial.

The Evicore Guidelines are applicable and consistent with current medical practice. As multiple criteria not met, the denial was reasonable, as it was based upon current scientific literature.