Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvean inpatient hospital admission for a total knee replacement surgery.You asked the Plan to pre-approvethe requested services. You say that the enrollee has severe osteoarthritis of the left knee.The Plan denied your request. The Plan says that the requested surgery is not medically necessary at this time.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found thatthe enrollee had chronic left knee pain and instability. Past medical history was positive for chronic obstructive pulmonary disease, stroke, and heart attack. Conservative treatment had included activity modification, Tylenol, weight loss, physician-directed home exercise, and corticosteroid injection. This enrollee presents with persistent left knee pain, stiffness, and instability. Functional limitations are noted in activities of daily living and ambulatory tolerance. Pain interferes with sleep. There is reported radiographic evidence of severe medial compartment osteoarthritis, and mild patellofemoral compartment narrowing. His body mass index is less than 32. Evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Current evidence based medical guidelines support total knee replacement for treatment of this enrollee's severe left knee osteoarthritis. Therefore, the request for left total knee replacement is medically reasonable and necessary to treat the enrollee's left knee severe osteoarthritis.Although,the records do not specifically state that the physician expected the enrollee's care to span 2 midnights, inpatient admission would be reasonably indicated in this enrollee's scenario given the significant medical history of chronic obstructive pulmonarydisease, stroke, and heart attack. This would be to allow for vital sign, hemodynamic, and neurovascular monitoring, deep vein thrombosis prophylaxis, cardiopulmonary care, medication and physical therapy stabilization for safe transfer to home. Therefore, the request for inpatient admission would be considered medically reasonable and necessary for the left total knee replacement. 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 services have been met.Therefore, we decided that the Plan has to pre-approvean inpatient hospital admission for a total knee replacement surgery.If the Plan does not agree with our decision,they can ask us to opena case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, wewill send you a letter.