Wiki Question for Alan Pechacek MD

Orthocoderpgu

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AETNA has decided that degenerative meniscal debridement (Meniscectomy) is "Experimental" now.

I'm sure that you have treated many degenerative tears over the years.

Do degenerative tears have an outcome that is far less than traumatic meniscal tears? (Leading to this decision maybe)

Just wondering why AETNA would make this decision.

The clinical staff that I have spoken with have all said that treating a degenerative meniscus tear is productive, however since these patients are usually older, other pathology may lead to continued knee pain after a mensicectomy.

Your thoughts?
 
Oh Boy! This is a challenging subject to discuss, but I will try to give my perspective. First off, Aetna is probably the worst "Health Insurance Company" to try do deal with. My experience over the years is/was that they will do their very best to deny anything and everything, even if the Orthopedic problem is real and the treatment otherwise correct and appropriate. The last place I practiced was a Multi-specialty Clinic, for 24 years, that would not even write a contract with Aetna, pretty much for these reasons. The only reason they started taking Aetna recently is that the major hospital in the community (a large employer) had Aetna as their insurer, and many of their employees were patients of our Clinic. So the fact that you are having trouble with Aetna is no surprise to me.

As for the issue of "Degenerative Meniscal Tears," they are common. Menisci can degenerate and tear on their own over time. The meniscus is not very good tissue, and when it starts to wear out, the process just keeps going. This includes the fact that there may be no other contributing factors. As such, "Degenerative Meniscal Tears" can occur by themselves. On the other side of the coin are the degenerative processes of the knee joint that also develop and progress over time, and which include degeneration of the menisci by their wearing out or getting "ground up" in this process. So there are sort of two ways to get to a "Degenerative Meniscal Tear." In ICD-10, these are in the M23.3 Code Set: Other Meniscal Derangements, which includes the synonyms of degenerated meniscus, detached meniscus, and retained meniscus. Contrary to ICD-10, not all old or chronic meniscal derangements are due to "old tear or injury," and in particular Old Bucket-handle Tear (Code Set M23.2). I don't know why ICD-10 was written this way, and I am in no position to rewrite it. An old, chronic meniscal tear is an old, chronic meniscal tear! Why they are separated is beyond me.

Anyway, the controversy regarding surgical treatment of chronic "Degenerative Meniscal Tears" goes back several years where someone in a retrospective study concluded that arthroscopic surgical treatment of knee arthritis with the surgical treatment of the torn meniscus was no better than other non-operative treatment of arthritis (plus meniscal tear) by such methods as Joint Lavage (which is Irrigation of the joint by a large volume of saline) or other methods. This "Study" recommended against arthroscopic surgery for knee arthritis and the degenerative meniscal tears when present, i.e. surgical treatment of degenerative meniscal tears is not effective and not indicated. As you might expect, this raised all sorts of Hell in the Orthopedic Community, and there were many studies in the Orthopedic "Literature" that countered this and supported the surgical treatment of Degenerative Meniscal Tears, contradictory to their results. In fact, if I remember correctly, the "Study" alluded to was not done by Orthopedic Surgeons, but by Internal Medicine Physicians. This is what insurance companies, including CMS, have "latched on to" as it regards the surgical treatment of Degenerative Meniscal Tears and their reason for denying claims. Don't confuse them with facts, their minds are made up!

Degenerative (Primary) and the other types of Osteoarthritis of the Knee (Code Set M17.) is very common. The symptoms are many and include pain of varying severity, aching, soreness, night pain, stiffness, decreased ambulatory activity tolerance, difficulty going up and/or down stairs/ladders, difficulty sitting down and getting back up, squatting, kneeling, crawling, the sensation of locking &/or catching, buckling and/or giving out/way ("Trick Knee"), popping, snapping, crunching, rubbing (crepitation) with or without associated increased or sudden pain, to name most of them. As it relates to "Degenerative Meniscal Tears" in all of this, there are some more specific symptoms and objective findings that Orthopedic Surgeons would call "Mechanical Symptoms" and that we consider to be meniscal tear related. These include pain localized to a specific place along the joint line (usually medial) that may occur suddenly or quite severely during weight bearing activities and/or with rotation/turning/twisting of the knee. This may be associated with the sensation of catching or locking at the time, and also the sensation that the knee is going to buckle or give out. The patient may describe feeling that something suddenly shifted, slipped, or moved in the joint where and when the pain occurs, and may also relate a sense of a click or pop in their knee at that moment. Objectively, there may be localized and increased tenderness along the joint line, a tender "bulge" on the joint line (the meniscus may be extruded from the joint), a painful click or pop along the joint line during motion in flexion &/or extension that may reproduce their subjective symptoms. There may be a painful click or pop with internal or external rotation of the tibia on the femur while going through the range of motion (McMurray's Test/Sign). If these "specific" symptoms and signs are present in an Osteoarthritic Knee, and there is MRI evidence of a chronic tear, then arthroscopic surgical treatment would be appropriate in my opinion.

The arthroscopic surgical treatment of Osteoarthritis of the knee, with or without a meniscal tear which is almost always present, is somewhat controversial. No Orthopedic Surgeon with any time and experience in the field could say that he/she can "cure" arthritis with arthroscopic surgical techniques or procedures. You can't "cure" Osteoarthritis with an arthroscope, but certain aspects of it can be treated with some success. I have had plenty of experience discussing arthroscopic surgery with patients. I describe the procedure to them as a "house cleaning" of the joint in that I will do all that I can reasonably do to the abnormal arthritic findings in the joint, including treating the meniscal tear(s), but that when I was done, they still had Arthritis. No matter how much better they might be, sooner or later their arthritic problems would return. I advised them also that they may be no better, a little better, some better, or a lot better for a period of time, but I was unable to predict the result accurately. However, if the patient had what I would consider to be a significant "Meniscal Element" to their problem, then surgical treatment of the meniscus (along with everything else I could do) was usually very beneficial. So, in that respect, I do not consider surgical treatment of "Degenerative Meniscal Tears" too be "experimental," but therapeutic.

I hope that this long-winded answer is helpful to you ("In for a penny, in for a pound.") It doesn't answer the problem of Aetna for you. Other than to "appeal" their opinion with "volumes" of documentation of history, symptoms, supportive physical findings, and clinical studies (MRI, etc.), Operative Reports, and Follow up notes indicating that the patient's symptoms are much improved (particularly the meniscal related symptoms), all I can say is stop taking Aetna.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
Thank you Doctor ! All that information really helps. I will spread the word !!!

I have to tell you about an experience with UHC.

A patient who lived in a small town hundreds of miles away fell through the floor of a house and was severely impaled by the wood of the floor when he hit the cement basement. He was flown in and our hospital had the only trauma center available. We did not take UHC at the time because they are much like AETNA.

Because our facility was not a participating facility with UHC they denied the hospital bill stating:

"Since this is not a participating facility the patient's policy would only provide coverage in an emergency situation"

If this was not an emergency, nothing is. He would have bleed out long before getting here by ground ambulance.

Yes, they eventually paid, but their initial denial is just hilarious!
 
Thank you Doctor ! All that information really helps. I will spread the word !!!

I have to tell you about an experience with UHC.

A patient who lived in a small town hundreds of miles away fell through the floor of a house and was severely impaled by the wood of the floor when he hit the cement basement. He was flown in and our hospital had the only trauma center available. We did not take UHC at the time because they are much like AETNA.

Because our facility was not a participating facility with UHC they denied the hospital bill stating:

"Since this is not a participating facility the patient's policy would only provide coverage in an emergency situation"

If this was not an emergency, nothing is. He would have bleed out long before getting here by ground ambulance.

Yes, they eventually paid, but their initial denial is just hilarious!

I am sorry to hear of your experience with UHC, but my opinion of them is about the same as Aetna. I have no "love" for any of them. I hope my response above is of help to many of you.

Alan Pechacek, M.D.
 
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