AAOS intervention prompts state to reconsider Medicaid coverage decision

In November 2011, the New York State Department of Health issued a new coverage guideline for knee arthroscopy. Under the guideline, the department planned to discontinue payments under Medicaid for all arthroscopic knee surgeries. The decision cited the AAOS clinical practice guidelines (CPGs) on treatment of osteoarthritis (OA) of the knee as one of the reasons for discontinuing coverage.

The AAOS quickly responded with a letter from AAOS President John R. Tongue, MD, citing the Academy’s belief that “the work group has misinterpreted some of the source documents they cite as evidence in support of their recommendations.”

The letter pointed out that the guideline is “evidenced-based and much more nuanced than the summary indicates.” It noted that the CPG “recommends against performing arthroscopy with débridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee,” which is very different from a recommendation against all knee arthroscopies in patients with symptomatic knee OA.

In fact, noted Dr. Tongue, arthroscopic débridement or lavage is just one of several arthroscopic procedures that may be performed for OA of the knee. Other recommendations in the CPG supported the use of arthroscopic surgery in patients with symptomatic OA of the knee, in particular for partial meniscectomy or loose body removal.

The AAOS recommended that the department take a narrower approach in applying the noncoverage decision and confine it only to arthroscopic lavage and débridement when the primary diagnosis is symptomatic OA of the knee, as stated in the AAOS guideline.

In April 2012, the department adopted the AAOS recommendations and will continue to cover other knee arthroscopy procedures, including partial meniscectomy or loose body removal when there are signs or symptoms of a torn meniscus or loose body.

AAOS is committed to responding similarly to other public and private payers who misapply AAOS CPGs and other AAOS positions. For more on this and other efforts to ensure that AAOS CPGs are used appropriately, see the interview with AAOS Council on Research and Quality Chair Kevin J. Bozic, MD, MBA.