Diagnosis: Left knee pain
Treatment: 27486 & 27487 - Inpatient total knee arthroplasty
The insurer denied the 27486 & 27487 - Inpatient total knee arthroplasty.
The denial is overturned.

This is a male who underwent bilateral total knee arthroplasty (TKR). He reported pain to his left knee with no associated injury. He was found to have an effusion, night sweats and C-reactive protein (CRP) / erythrocyte sedimentation rate (ESR) of 15.4/48. The patient was diagnosed with septic arthritis. Cultures were completed and infection was found.

The patient underwent incision, drainage and poly exchange. He received medications for pain and intravenous (IV) antibiotics. A peripherally inserted central catherater (PICC) line was placed. Infectious Disease (ID) consultation was completed. The patient was ambulating with crutches. His cultures grew coagulase negative staphylococcus (staph). He was discharged with IV therapy to continue at home.

Yes, the proposed treatment was medically necessary.

This patient has an infection to his left total knee. Treatment options require accurate identification of the organism and urgent surgical attention. It is imperative to decrease the infectious load as catastrophic complications can occur.

Orthopedic management of this condition would depend upon the timing and organism found. This patient has reported duration of symptoms less than 30 days. He likely had new onset infection. It would be appropriate to perform the irrigation and debridement. Most surgeons would exchange the poly as the undersurface could harbor biofilm and bacteria. A thorough irrigation, debridement and poly exchange would thus be indicated. It would not be appropriate to revise the well-fixed components at this time.

The Evicore criteria for poly exchange make no mention of an irrigation and debridement (I&D) being performed at this same time; "this is not an isolated poly exchange, see need for I and D".

A search was performed of current orthopedic literature. The standard of care for a new onset of infection with organism of low virulence is irrigation, debridement and poly exchange. There are no other options.

The procedure was complex and extensive. Exposure required full opening of the knee with large incision. The procedure would be expected to be painful and require intravenous (IV) analgesia. IV antibiotics were essential as well with placement of PIC line. This type of operation cannot be completed on an ambulatory surgical unit (ASU) or observation level of care.

Therefore, codes 27486 & 27487 - inpatient total knee arthroplasty, was medically necessary.