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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.  The rules 
say 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: 
o Distal femur fracture; o Proximal tibia fracture; 
o Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 
o Avascular or other form of osteonecrosis of the knee; 
o Rheumatologic changes precluding or inconsistent with rehabilitation. 
5. Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the 
following: 
o Loosening, fracture, or mechanical failure of one or more components; 
o Technical or functional failure of previous knee surgery, e.g. unicompartmental knee 
replacement; 
o Previous osteotomy or partial arthroplasty; 
o Infection; 
o Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee 
malalignment; 
o Bearing surface wear leading to symptomatic synovitis; 
o Tibiofemoral or extensor mechanism instability; or 
o Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the 
extent to preclude employment or functional activities. 
The following are considered not reasonable and necessary and therefore will be denied: 
1. TKA and THA will not be considered reasonable and necessary when the above indications are not met. 
2. Medicare will consider a total knee replacement or total hip replacement not medically reasonable and 
necessary when the following contraindications are present: 
o Active infection of the hip or knee joint or active systemic bacteremia 
o Active skin infection or open wound within the planned surgical site of the hip or knee 
o Progressive neurological disease, etiologic for pain, instability or disability. 
You can find this information in Medicares Local Coverage Determination (LCD)  Lower Extremity Major 
Joint Replacement (Hip and Knee) (L36007).