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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 say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 
The rules say that Medicare will consider Total Knee Arthroplasty (TKA) medically reasonable and necessary 
when three or more of the following criteria are met: 
 
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; 
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. 
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; 
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 
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: 
 
TKA and THA will not be considered reasonable and necessary when the above indications are not met. 
Medicare will consider a total knee replacement or total hip 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 these rules in Local Coverage Determination (LCD) Lower Extremity Major Joint Replacement 
(Hip and Knee) (L36007). 
 
If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
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.