Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve viscosupplementation of the right knee. We decided that the 
Plan does not have to pre-approve viscosupplementation of the left knee.  
 
You asked the Plan to pre-approve viscosupplementation of both knees. You say that the enrollee meets all the 
criteria for injections and the documentation provided supports medical necessity. The Plan says that based on 
the clinical information provided, the request is not medically necessary. 
 
We decided that the Plan has to pre-approve viscosupplementation of the right knee.  
 
The Plan follows 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 viscosupplementation of both knees. 
Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is an 
obese woman who has bilateral osteoarthritis of her knees. She had X-rays of the Right knee and subsequently 
had an intra-articular steroid injection. Our physician reviewer found that the requested viscosupplementation 
of the right knee 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 viscosupplementation of both knees have been met. Therefore, we decided that 
the Plan has to pre-approve viscosupplementation of the right knee.  
 
We also decided that the Plan does not have to pre-approve viscosupplementation of the left knee. 
 
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 viscosupplementation of the left knee. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation of X-rays of the Left knee and no documentation of a steroid injection in the Left knee. Our 
physician reviewer found that viscosupplementation of the left knee is 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 viscosupplementation of the left knee have not been met. Therefore, we decided 
that the Plan does not have to pre-approve viscosupplementation of the left knee. 
 
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.