Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Problem/Pain
Treatment: Outpatient Knee Surgery (29877 x 1, 29876 x 1, 29874 x 1, 29880 x 1)
The health plan denied: Outpatient Knee Surgery (29877 x 1, 29876 x 1, 29874 x 1, 29880 x 1)
The determination is: Overturned

The patient is a female diagnosed with synovitis and medial and lateral meniscectomy as well as recurrent anterior cruciate ligament (ACL) tear of the left knee. She is noted to have comorbid obesity, gastroesophageal reflux disease (GERD), seasonal allergies, shoulder pain, temporomandibular joint (TMJ) dysfunction, thoracic outlet syndrome, migraine, and Chari malformation.

An initial progress note documents a treatment for the knee included injection. A follow-up progress note from the treating provider states that the patient suffered an injury to the knee, and she reported medial and lateral pain. She completed physical therapy without improvement. She reported ongoing instability. She was utilizing a knee brace. The provider recommended magnetic resonance imaging (MRI). An MRI report of the left knee documented a tear of the ACL, lateral meniscal tear, and cartilage erosion in the medial and lateral compartments. Another progress note documents ongoing symptoms in the left knee with increased ability while utilizing a brace.

A clinical progress note from the treating provider documents that the patient presented for a preoperative visit of left knee. An exam of the knee documented good motion, tenderness of the medial and lateral joint line, positive McMurray, and no instability. The MRI documented failure of the ACL graft and lateral meniscal tear. The provider recommended revision ACL reconstruction and partial meniscectomy. An operative note documents that the patient had a preoperative diagnosis of left knee recurrent ACL tear and medial and lateral meniscal tears, a postoperative diagnosis of left knee recurrent ACL tear, medial and lateral meniscal tears, loose body, and synovial hypertrophy. She underwent left knee revision ACL reconstruction, partial medial and lateral meniscectomy, loose body removal, and synovectomy. The operative procedure indicates that the patient was found to have a tear of the anterior horn of the medial meniscus, which was debrided, synovial hypertrophy and scar tissue of the anterior medial compartment, a lateral meniscal tear for which partial meniscectomy was performed, and synovectomy was also performed in the lateral and parapatellar compartment.

At issue is the medical necessity of outpatient knee surgery. The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of outpatient knee surgery is medically necessary for this patient.

Current medical literature recommends meniscectomy for symptomatic meniscal tears not improved with conservative treatments. Synovectomy is supported for documented synovitis. In this circumstance, the patient was diagnosed with a recurrent left knee ACL tear and lateral meniscal tear. She was approved for operative intervention to include meniscectomy and ACL reconstruction. During operative intervention, the patient was found to have an additional medial meniscal tear, which was unstable, as well as synovial hypertrophy and scar tissue in all 3 compartments of the knee. The provider performed a medial and lateral meniscectomy and synovectomy at the time of ACL reconstruction. Given that the patient was found to have a medial meniscal tear during operative intervention, medial meniscectomy in addition to the approved lateral meniscectomy was medically necessary. It would be unethical to not address the medial meniscal tear at the time of operative intervention. Additionally, given the documented synovial hypertrophy, synovectomy would be supported at the time of surgical intervention as it would also be unethical to not address synovial hypertrophy as this can lead to arthrofibrosis. Therefore, the completed medial and lateral meniscectomy and major synovectomy were medically necessary.