Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluid flow or fluid GF, 1 cc and arthrocentesis, 
aspiration and/or injection; small joint, bursa or ganglion cyst provided on February 9, 2022. 
 
You asked the Plan to pre-approve fluid flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection; 
small joint, bursa or ganglion cyst. You say that the services were medically necessary. The Plan denied your 
request. The Plan says amniotic membrane and amniotic fluid, injection of human amniotic fluid is considered 
experimental, investigational and/or unproven for all indications. 
 
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 fluid flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst. Our reviewer says that the 
requested fluid flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection; small joint, bursa or 
ganglion cyst is not considered medically reasonable and necessary. Our physician reviewer found that it is 
well established that this enrollee is suffering with pain to the metatarsal phalangeal joints and interdigital 
spaces left foot. The medical documentation does not support prior conservative treatments including orthotic 
therapy, icing, stretching, shoe gear modification, and or corticosteroid injections. Medicare guidelines advise 
that Medicare will pay for items or services that are reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body member. The treatments must be safe and 
effective, not mainly for the convenience of the patient or the physician, not experimental or investigational, 
appropriate in that the treatment is furnished in accordance with accepted standards of medical practice for the 
diagnosis or treatment of the patient's condition or to improve the function of a malformed body member, 
furnished in a setting that is appropriate, and a treatment that meets but does not exceed the patient's medical 
need and finally, the treatment must be as beneficial as an existing and available medically appropriate 
alternative. Amniotic fluid injections to facilitate healing of soft tissue and reduce inflammation is still 
considered experimental. It has certainly not shown to be superior to steroid injections, offloading of pressure, 
icing, bracing, or physical therapy. Amniotic fluid injections are not considered standard of care at this point, as 
more studies are needed in order to solidify their efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fluid flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection; small 
joint, bursa or ganglion cyst have not been met. Therefore, we decided that the Plan does not have to pre-
approve fluid flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection; small joint, bursa or 
ganglion cyst provided on February 9, 2022.