Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) (CPT code 29876), arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture (29879), and arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed (29881).

You asked the Plan to pre-approve the services. You say that the knee surgery should be covered based on the fact that you have been having knee problems for several years. You state your knee locks up on you and causes you to fall. The Plan denied your request. The Plan says you do not have imaging evidence of a meniscal tear or a microfracture (small hole in the bone) or bony lesion (area of the bones that are changed or damaged) or synovitis (inflammation (swelling, pain, and warmth) of a synovial membrane, which is a layer of connective tissue that lines a joint, such as the knee). The Plan states there is no documented history of a specific chronic inflammatory joint disease that would cause synovitis.

The Plan must follow 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. In addition, the CT scan does not demonstrate meniscal pathology. Moreover, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the overall noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for arthroscopy, knee surgical; synovectomy, major 2 or more compartments (eg, medial or lateral) CPT 29875; arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture CPT 28979; and arthroscopy, knee, surgical with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s) when performed CPT 29881) is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) (CPT code 29876), arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture (29879), and arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed (29881).