Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the computer-assisted musculoskeletal surgical navigation system that was provided during a left total knee arthroscopy. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. Findings:  Two out of three physician reviewer found that a review of the records indicates the enrollee underwent total knee arthroplasty. 43 days later, the enrollee presented for a postoperative evaluation. The records noted that the knee surgery demonstrated extensive scar tissue and severe attenuation of the medial collateral ligament. The provider noted that the enrollee would continue with physical therapy. The medial literature concluded that when an experienced surgeon performed total knee arthroplasty, no significant difference was identified at the 5-year follow-up between patients who underwent computer-assisted versus manual total knee arthroplasty. The authors concluded that patient specific instrumentation (PSI) for total knee arthroplasty has not reliably demonstrated improvement of postoperative limb or component alignment compared with standard instrumentation.  This patient presented with a history of progressive left knee pain. Her past medical history was positive for remote tibia and fibular fracture with a post-traumatic midshaft diaphyseal deformity of the tibia. X-rays of the left knee documented severe degenerative change, which was evident by significant medial compartment joint space narrowing and tricompartmental osteophyte formation, small to moderate joint effusion. She underwent a left knee total knee arthroplasty with computer-assisted navigation. The superior efficacy of computer-assisted surgery for the total knee arthroplasty is not supported by evidence-based medical guidelines or peer-reviewed literature. There is a lack of large volume, high quality clinical trials that confirm the clinical benefits (ultimate outcomes of functionally improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in total knee arthroplasty. The records did not document a significant left knee deformity to support the use of computerized navigation for this patient. Therefore, the computer-assisted musculoskeletal surgical navigation system that was provided during a left total knee arthroscopy was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested treatment is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.