Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee replacement surgery. In a multicenter longitudinal cohort study, colleagues concluded that the risk/benefit tradeoff for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility and a BMI less than 40. Li and colleagues conducted a national cohort sample study of 2,040 hip and 2,964 knee replacements, which looked at pain and function according to BMI status. Within this sample, 14 percent of hip and 25 percent of knee patients were severely or morbidly obese. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing total joint replacement to relieve symptoms. A case-controlled study with 134 hip and 50 knee arthroplasties in obese patients over 11 years. The study concluded that despite lower clinical scores, the obese patients were satisfied with the results of their surgery and have an equivalent mid-term survival rate. They indicated that it would be unreasonable to deny patients arthroplasty surgery purely on the basis of a BMI indicating obesity. In this case, the patient presents with progressive worsening right medial knee pain with mechanical symptoms of locking, popping, clicking, and swelling. Pain is reported as severe and limiting his ability to walk. Clinical examination findings are consistent with radiographic evidence of severe osteoarthritis of the right knee, bone-on-bone in the medial compartment. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment, including NSAIDs, analgesics, bracing, cane, weight loss and steroid injections, without sustained improvement is documented. The patient has reportedly lost weight, but has been recommended to lose 26 more pounds in order to be a candidate for surgery (BMI under 40). He has reported difficulty with additional weight loss due to his knee pain with weight bearing activity and exercise. The patient has met other evidence-based medical criteria for total knee replacement. Current evidence-based medical literature supports proceeding with total knee replacement in the setting of the current BMI, indicating that obesity itself should not be a deterrent to undergoing total joint replacement to relieve symptoms. Therefore, the requested right knee replacement surgery is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.