Utilization Review Checklist
Knee Osteoarthrosis
Derived from the ACOEM Knee Disorders Guideline, edition 3 December 2019, as adopted into the California MTUS 21 September 2020. CPT 27447, 27446. ICD-10 M17.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
Procedures — the guideline treats each separately
Total knee arthroplasty for moderate to severe arthritides
Strongly Recommended. Knee arthroplasty is strongly recommended for severe arthritides.
Strength of Evidence — Strongly Recommended, Evidence (A) · p. 107
Indications — all of the following:
Severe knee degenerative joint disease unresponsive to non-operative treatment
“Indications – All of the following present: 1) severe knee degenerative joint disease that is unresponsive to non-operative treatment (rare cases may include osteonecrosis of the distal femur or tibial plateau with collapse or lack of response to non-operative treatment); 2) sufficient symptoms and functional” — p. 107
AND
Sufficient symptoms and functional limitations, such as impairments of activities of daily living or occupational tasks
“limitations, such as impairments of activities of daily living or occupational tasks, and 3) failure to successfully manage symptoms after a prolonged period of a conservative management plan” — p. 108
AND
Failure after a prolonged period of a conservative management plan including NSAIDs, exercise, physical or occupational therapy, and where appropriate weight reduction, viscosupplementation and corticosteroids
“3) failure to successfully manage symptoms after a prolonged period of a conservative management plan that included NSAIDs, exercise, physical or occupational therapy, and where appropriate, weight reduction, intraarticular viscosupplementation, and corticosteroids.” — p. 108
Strongly Recommended on (A) evidence — the strongest grade ACOEM gives, and a denial against a note documenting all three indications is worth appealing. Note the conservative plan the guideline names is broad: NSAIDs, exercise, physical or occupational therapy, and where appropriate weight reduction, intraarticular viscosupplementation AND corticosteroids. It sets no number of months.
Unicompartmental knee arthroplasty for largely unicompartmental disease
Recommended. Unicompartmental arthroplasty is recommended for largely unicompartmental disease.
Strength of Evidence — Recommended, Evidence (C) · p. 108
Indications — required:
Largely unicompartmental disease
“Unicompartmental arthroplasty is recommended for largely unicompartmental disease.” — p. 108
Recommended for largely unicompartmental disease on (C) evidence. The guideline cites a trial with 5- and 15-year follow-up finding better range of motion and 'excellent' results compared with total arthroplasty in that select group — worth quoting if the choice is questioned. Document which compartment is involved and that the others are relatively spared.
Chondroplasty and debridement for knee osteoarthrosis
Moderately Not Recommended. Chondroplasty and debridement are moderately not recommended for treatment of knee osteoarthrosis.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence moderate · p. 105
Indications — required:
Chondroplasty and debridement requested for knee osteoarthrosis
“Chondroplasty and debridement are moderately not recommended for treatment of knee osteoarthrosis.” — p. 105
Moderately NOT recommended on (B) evidence, resting on a high-quality SHAM-CONTROLLED trial that found no benefit. This is among the best-evidenced negative findings in any of these chapters. A request will very likely be denied and further documentation will not change it.