Diagnosis: Right knee pain
Treatment: Joint Surgery (removal of one knee cartilage using an endoscope, repair of anterior cruciate ligament or knee)
The insurer denied the Joint Surgery (removal of one knee cartilage using an endoscope, repair of anterior cruciate ligament or knee).
The denial is overturned.

This patient is a male who reported a five day history of right knee pain. He stepped awkwardly and twisted his knee. He was found to have tenderness, effusion and positive Lachman. An magnetic resonance image (MRI) showed an anterior cruciate ligament (ACL) tear and possible meniscal tear. He underwent an anterior cruciate ligament (ACL) reconstruction with partial medial meniscectomy.

Yes, the proposed surgery was medically necessary.
There was evidence of a traumatic injury with resultant anterior cruciate ligament (ACL) deficiency and torn meniscus. The patient had instability and effusion. A pain generator had been defined. His ligament and meniscus was torn. This type of injury will not heal with conservative management.

Per the Evicore guidelines:
Meniscal surgery:
Conservative treatment is not required if at least two of following four criteria are met:
1) Positive McMurray's or positive Thessaly test
2) twisting or acute injury of the knee , MET
3) locked knee/inability to fully extend the knee NOT MET
4) knee effusion, MET

The meniscus tear is traumatic; it is different than degenerative. The patient has a new injury from trauma. There would be no restriction to performing the surgery. As criteria met, the surgical procedure would be indicated.

The records were consistent for a traumatic event and resultant instability. The magnetic resonance image showed a torn ligament and torn meniscus. The next step would be surgery to repair the damage.