Why MA Plans Denies Knee Arthroscopy
Degenerative meniscal tear in patient over 40
Conservative therapy not exhausted
Imaging does not support mechanical symptoms
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
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 MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- AAOS Clinical Practice Guidelines for Knee Arthroscopy
- AIM Specialty Health MSK Guidelines
Relevant CPT Codes
Specialty: Orthopedics
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