Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cruciate ligament (ACL) surgery, without quitting smoking at least one week prior to the surgery. Smoking has well-known negative effects on tissue healing. In a study regarding graft selection in ACL reconstruction for smoking patients, Kim and colleagues found unsatisfactory outcomes with regard to stability and functional scores in the smoking group compared with the nonsmoking group. The authors found that in smokers, the patients receiving an Achilles tendon-bone allograft had poorer outcomes than those with autografts, and recommended the bone-patellar tendon-bone autograft for ACL reconstruction in a smoking patient. In examining risk factors for hospital admission after ACL reconstruction, Bokshan and colleagues found that variables associated with the need for admission included smoking. In a systematic review of which patient determinants and injury factors, before ACL reconstruction by arthroscopic single-bundle techniques, affected postoperative rehabilitation, De Valk and colleagues concluded that smoking, high body mass index, quadriceps strength, and range-of-motion deficits affected rehabilitation negatively. In this case, the patient is being treated for a torn repaired ACL and presented with right knee instability from a knee injury. The patients initial pain had since resolved, but the patient reported that the knee felt unstable and that he did not trust it. On examination of the right knee, there was trace effusion, a range of motion of zero to 135 degrees, a positive Lachman test, limited pivot shift test due to patient guarding, and strength measured at five out of five. An MRI showed high-grade, partial-thickness tear of the reconstructed ACL graft, mainly involving the mid-segment, torn fibers displacing into the anterior interval, cystic enlargement of the femoral and tibial tunnels, no significant anterior translation of the tibia relative to the femur, and moderate joint effusion. The records noted that the patient was a current smoker and that the provider recommended tobacco cessation at least for the week prior to surgery. Records indicate the patient elected to use an allograft for the requested surgery. Given that current medical literature demonstrates increased risk factors of poorer healing and higher complication rates in smokers, this specific elective surgical procedure in the setting of smoking is not medically indicated. Therefore, ACL surgery, without the patient quitting smoking at least one week prior to the surgery, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.