Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that Medicare will consider Total Knee Arthroplasty (TKA) medically reasonable and necessary 
when three or more of the following criteria are met: 
 
1.  Advanced joint disease demonstrated by radiographic supported evidence or magnetic resonance imaging 
(MRI), e.g., fracture or deterioration, distortion of joint surfaces, subchondral cysts, subchondral sclerosis, 
periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis; 
 
2. History of unsuccessful appropriate conservative therapy that is clearly documented in the pre-procedure 
medical record. Non-surgical medical management is usually implemented for 3 months or more to assess 
effectiveness. Conservative treatment as clinically appropriate for the patients current episode of care typically 
includes one or more of the following: anti-inflammatory medications; analgesics; flexibility and muscle 
strengthening exercises with supervised physical therapy. 
 
3. Pain with functional disability due to arthritis or trauma to the knee joint; activities of daily living (ADLs) 
are diminished despite compliance with plan of care including activity restrictions as is reasonable, assistive 
device use, weight reduction as appropriate or therapeutic injections into the knee as appropriate; 
 
4. Distinct structural abnormalities such as: 
- Distal femur fracture; 
- Proximal tibia fracture; 
- Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 
- Avascular or other form of osteonecrosis of the knee; 
- Rheumatologic changes precluding or inconsistent with rehabilitation 
 
5. Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the following: 
- Loosening, fracture, or mechanical failure of one or more components; 
- Technical or functional failure of previous knee surgery, e.g. unicompartmental knee replacement; 
- Previous osteotomy or partial arthroplasty; 
- Infection; - Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee 
malalignment; 
- Bearing surface wear leading to symptomatic synovitis; 
- Tibiofemoral or extensor mechanism instability; or 
- Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the extent to 
preclude employment or functional activities. 
 
Limitations 
The following are considered not reasonable and necessary and therefore will be denied: 
1. TKA will not be considered reasonable and necessary when the above indications are not met. 
2. Medicare will consider a total knee replacement not medically reasonable and necessary when the following 
contraindications are present: 
- Active infection of the hip or knee joint or active systemic bacteremia 
- Active skin infection or open wound within the planned surgical site of the hip or knee 
- Progressive neurological disease, etiologic for pain, instability or disability 
 
You can find this information in the Local Coverage Determination (LCD): Lower Extremity Major Joint 
Replacement (Hip and Knee) (L36007). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.