Diagnosis: Joint problem, pain
Treatment: Surgical Services

This case describes a patient with a complaint of left knee pain that began two years earlier as a result of a fall down some stairs. The patient's plain x-rays and a magnetic resonance imaging (MRI) of the affected right knee confirmed osteoarthritis of the medial and patellofemoral compartments, as well as a complex medial meniscus tear. The patient attempted oral medications and a steroid injection, which failed to provide lasting pain relief. The patient subsequently underwent right knee arthroscopic surgery. The health plan's determination of medical necessity is upheld in whole.
The requested health treatment of Knee Arthroscopy was not medically necessary for this patient. The rationale for this determination is based upon a review of the current, peer-reviewed orthopedic literature on this topic, which has proven that arthroscopic knee surgery in knees with osteoarthritis is not an effective treatment.
This conclusion was drawn in recent studies published in the peer-reviewed literature by Katz and colleagues in the New England Journal of Medicine and by Steadman and associates in the Arthroscopy Journal.
The rationale for this determination is based upon the provided medical and radiological records which document significant osteoarthritis in this patient's right knee along with a degenerative medial meniscal tear. This determination was based on the provided medical records, which clearly document osteoarthritic changes in this patient's right knee, as well as an associated degenerative medial meniscal tear for which arthroscopic knee surgery was eventually performed. The current, peer-reviewed orthopedic literature does not support the efficacy of this procedure. It has been found to be less effective than more conservative treatment options, such as physical therapy, in a study published by Katz and associates in the New England Journal of Medicine in 2013. Therefore, the right knee arthroscopic surgery was not medically necessary in this case.