Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. We decided that the Plan does not 
have to pre-approve a robotic surgical system and computer-assisted musculoskeletal navigation.  
 
You asked the Plan to pre-approve an inpatient hospital admission, a robotic surgical system, and computer-
assisted musculoskeletal navigation.. You say that the records provided support the need for the services in 
dispute. The Plan says that the surgery is not on the inpatient-only list and is approved as an ambulatory 
procedure. The Plan says that there is no documentation provided to support the expectation that the enrollee 
will require a greater than 2-midnight stay. The Plan says that the code being requested for the robotic surgical 
system is not valid. The Plan says that the current evidence-based medical literature does not support the 
routine use of computer-assisted navigated total joint arthroplasty over conventional total joint arthroplasty. 
 
We decided that the Plan has to pre-approve an inpatient hospital admission.  
 
The Plan follows Medicare rules. Medicare rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 an inpatient hospital admission. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found there is detailed 
documentation supporting significant past and/or current medical history that would place this enrollee at 
increased risk for peri-surgical complications requiring an inpatient stay. Therefore, the record does show that 
at the time of the request for an inpatient admission, the requesting physician reasonably expected that the 
patients necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital admission, a robotic surgical system, and computer-
assisted musculoskeletal navigation have been met. Therefore, we decided that the Plan has to pre-approve an 
inpatient hospital admission.  
 
We also decided that the Plan does not have to pre-approve a robotic surgical system and computer-
assisted musculoskeletal navigation. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered.  
 
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 a robotic surgical system and computer-
assisted musculoskeletal navigation. Our reviewer says that the criteria for coverage of these services have not 
been met. Our physician reviewer found there is no large volume, long-term/high-quality clinical studies that 
confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-
assisted surgery over standard surgical approaches in total knee arthroplasty. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested robotic surgical system and computer-assisted musculoskeletal navigation are not 
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 a robotic surgical system and computer-assisted musculoskeletal navigation 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a robotic surgical system 
and computer-assisted musculoskeletal navigation. 
 
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.