Knee Arthroscopy denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee surgery for the right knee. In a systematic review of the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee, researchers concluded that there was a benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. Researchers noted that while the role of arthroscopic debridement in the painful degenerative knee is controversial, arthroscopy may provide good symptomatic relief and sustained benefits in significantly symptomatic patients, especially in the presence of mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis. In this case, the patient has severe pain from osteoarthritis of the right knee.

A 57-year-old male enrollee has requested right knee arthroscopy for treatment of his right knee pain. Findings: The physician reviewer found that based on review of the available records, it is medically necessary for this patient to undergo the requested right knee arthroscopy for treatment of a meniscal tear as evidenced on MRI. The patient’s records document the patient initially had a bone contusion. The patient’s course of treatment was appropriate consisting of strict non weight-bearing with use of a scooter. This treatment for the osteonecrosis was successful as documented in a subsequent MRI. However, follow-up MRI also demonstrated evidence of a meniscal tear. Consistent with current guidelines, the next step in treatment is the requested right knee arthroscopy for management of this patient’s medical condition.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for lumbar and neck epidural corticosteroid (steroid) injections and/or bilateral ankle arthroscopy and bilateral knee arthroscopy followed by rehabilitation and physical therapy (PT) services.Lumbar transforaminal injection of steroid (LTFIS) is a treatment for radicular pain. Steroids are believed to have a therapeutic effect due to their anti-inflammatory properties. Smith and colleagues concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. The authors indicated that there is a lack of high-quality evidence demonstrating their effectiveness in the treatment of radicular pain due to spinal stenosis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for knee arthroscopy (CPT 29875, 29880, and 29877).Lamplot and Brophy concluded, “Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis.” Ji and colleagues indicate, “Positive McMurray sign implies good postoperative outcomes for the patients with meniscal tear associated with osteoarthritis. For patients with osteoarthritis, those whose positive McMurray signs are in line with their radiological findings indicate they are eligible candidates for arthroscopic meniscectomy.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Knee Arthroscopywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.