Why Anthem BCBS Denies Knee Arthroscopy
Degenerative meniscal tear in patient over 40
Conservative therapy not exhausted
Imaging does not support mechanical symptoms
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Building Your Medical Necessity Argument
Document mechanical symptoms (locking, catching, giving way)
Distinguish traumatic from degenerative tear
Note failure of 3+ months conservative management
Reference MRI findings showing displaced meniscal fragment
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- AAOS Clinical Practice Guidelines for Knee Arthroscopy
- AIM Specialty Health MSK Guidelines
Relevant CPT Codes
Specialty: Orthopedics
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