Diagnosis: Meniscus Tear

Treatment: Arthroscopic knee surgery

The insurer denied coverage for arthroscopic knee surgery.

The denial is upheld.

This is the case of a patient with history of cardiac transplant years ago and longstanding back issues including an extended fusion. The patient still receives treatment at the pain clinic and has had some associated back complaints. He believes that he developed some knee discomfort years following his cardiac transplant. The patient was evaluated previously and told he had a meniscus tear that needed treatment and, on another occasion, was told he was too young and there were some concerns regarding the location of treatment given his cardiac status. His pain has gradually worsened, and he reports the pain is worse over the medial joint line when pivoting, twisting, descending stairs and pushing an object with the inside of his foot. He had some temporary relief in the past with an injection, but his symptoms recur. Various options were discussed, including continued conservative care, pharmacotherapy, and surgical intervention. The patient opted to move forward with an arthroscopy.

The records show the patient was evaluated for the first time by a specialist. The complaint was right knee pain for a duration of years. His physical examination was significant for a flexion contracture (he was only able to extend to 10 degrees) with imaging studies showing degenerative changes (arthritis). These findings are consistent with progressive osteoarthritis.

The scientific literature reports people who undergo arthroscopy with underlying arthrosis do not do well. Recommendations are: this surgery should not be performed because there is an increased rate of progression to arthroplasty. Treating meniscal pathology in the presence of joint arthrosis does not address the underlying problem of a degenerative process.

Conservative course of treatment should be provided prior to surgical intervention. This would consist of a course of physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), brace and/or injections (cortisone). The records show non-operative treatment was discussed but not provided. Surgery was performed.

The post-surgical course was significant for ongoing problems with bracing/injections now recommended.

In conclusion, the operation was not necessary based upon clinical presentation of underlying osteoarthritis and lack of prior conservative management.

There were no extenuating circumstances to warrant the procedure. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the arthroscopic knee surgery provided is not substantiated. The insurer's denial is upheld.