Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total left knee replacement surgery. In a study of the appropriateness of total knee arthroplasties (TKA) in the United States, researchers found that the risk/benefit for TKA favored patients with intense or severe symptoms of knee osteoarthritis, who were at least 55 years old, had limited mobility, and had a body mass index (BMI) under 40 kg/m2. The authors noted that outcomes were much less favorable for patients with slight or moderate symptoms and functional loss, making the procedure not appropriate. Researchers report, A differentiated indication is decisive for a good outcome. Pain, limitations in quality of life because of osteoarthritis, radiological confirmation of osteoarthritis and inadequate response to conservative treatment should be reported. Moreover, medical history, clinical examination and radiographic findings need to be conclusive. Expectations need to be realistic and reasonable. When all of these criteria are met, the attending physician may indicate an operation. Finally, the patients level of suffering and discomfort defines the timing of an arthroplasty. Researchers conclude, Patients with less pain and higher Kellgren and Lawrence grades preoperatively had better function and pain outcomes one and two years after TKA. However, the effect of preoperative pain on the postoperative outcomes seems to become less important when the patient has radiographic evidence of more severe osteoarthritis. We believe that analysis of the severity of preoperative pain is an important proxy for optimal postoperative patient outcome. Medical literature notes that guidelines for managing hip and knee osteoarthritis advise extensive non-surgical treatment prior to surgery. The authors noted that of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain. In this case, the patient has post-traumatic osteoarthritis and chronic pain of the left knee. He has a history of two previous surgeries including partial meniscectomy followed by total meniscectomy. The patient reported increased swelling and stiffness, and that he was unable to fully straighten the knee or bend the knee very far. The patient reported aching and occasionally sharp pain. He had tried cortisone injections, bracing, and over-the-counter medications without relief. On examination, the patient had a range of motion of five to 95 degrees, 5 degree flexion contracture, and no extensor lag. There was crepitus with range of motion. There was mild effusion and anterior tenderness. The records noted that x-rays reported tricompartmental degenerative changes, most severe in the medial and patellofemoral compartment with bone-on-bone articulation, and significant sclerosis and osteophytosis throughout the knee. However, the records did not document trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures such as physical therapy or trials of viscosupplementation injections. Given that the submitted documentation does not document the failure of reasonable and comprehensive conservative measures, the requested service is not medically indicated. Therefore, total left knee replacement surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.