Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a knee arthroscopy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is supported when the results of advanced imaging shows that 
the tissue in the knee joint has weakened. 
 
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 the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was being treated for complex tear of medial meniscus, current injury, left knee; and 
bilateral primary osteoarthritis of the knees. She presented with long-standing left knee pain with a recent, 
increase in pain after a fall. The cortisone injection helped significant for about 4 days. Then she had a large 
painful pop in her knee (causing it to buckle while walking around her home.) She has not been able to fully 
bear weight since that time. She continues with marked flare-ups of knee pain. The exam reveals significantly 
decreased range of motion from 15 to 90 degrees in office with significant pain at end limits. McMurray?s is 
positive. The enrollee has significant pain to varus stress. The 8/24/21 MRI of the left knee has conclusions of: 
displaced meniscal tear; degenerative lateral meniscal tear; grade 3 articular cartilage degeneration of the 
medial femoral condyle and patellofemoral compartment; moderate joint effusion; Baker's cyst; PCL (posterior 
cruciate ligament) chronic partial-thickness intrasubstance tear. The provided documentation demonstrates 
subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative 
treatment modalities has been documented. The combination of findings reflects "unstable tissue flaps" 
including the meniscal "tears." The tissue in the knee has "weakened." Therefore, this request for left knee 
arthroscopy; knee arthroscopy with meniscectomy (medial or lateral including any meniscal shaving) including 
debridement/shaving of articular cartilage (chondroplasty), same or separate compartments when performed 
(29881) and arthroscopy, knee, debridement/shaving of articular cartilage (chondroplasty) is medically 
reasonable and necessary. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve a knee arthroscopy for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a 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, we will 
send you a letter.