Orthopedic and spine surgery: 30% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 51–64 Lower ext ortho · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for arthroplasty to the left knee. In this case, the patient was being treated for osteoarthritis and bone necrosis in the left…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for arthroplasty to the left knee. In this case, the patient was being treated for osteoarthritis and bone necrosis in the left knee. The patient recently presented with continued knee symptoms with localized pain over the medial joint line as well as pain throughout the patellofemoral joint. A review of the patient’s recent diagnostic imaging studies, including magnetic resonance imaging (MRI) and radiographs, does not clearly corroborate moderate left knee arthrosis/osteoarthritis. Overall, there are limited large-scale, long-term references showing the efficacy of the requested surgery in this clinical setting. Further, there is no compelling rationale presented or extenuating circumstances noted to support the medical appropriateness of this request as an exception. Therefore, the requested procedure, arthroplasty to the left knee, is not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46565

2. Upheld 2026 · Medical necessity · age 31–40 Arthroscopy · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a right knee arthroscopy. Surgical decision-making for meniscal pathology depends on the type, size, and location of the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a right knee arthroscopy. Surgical decision-making for meniscal pathology depends on the type, size, and location of the injury. Current literature notes that mechanical symptoms, including catching and locking, may have multifactorial causes and may not consistently respond to arthroscopic meniscectomy.In this case, the patient has previously used a knee brace and takes Norco for knee pain symptoms. However, the records do not adequately document trial and failure of recent, comprehensive conservative treatment measures, including formal physical therapy, a prescribed home exercise program, and nonsteroidal anti-inflammatory medication therapy.Given the lack of documentation supporting adequate conservative management, the requested right knee arthroscopy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46456

3. Overturned 2025 · Medical necessity · age 51–64 Spinal fusion · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for Ztildo patches and/or multi-level lumbar fusion.The records indicate that this patient presents with a history of spinal stenosis of the lumbar region with neurogenic…

   The physician reviewer found that a patient has requested authorization and coverage for Ztildo patches and/or multi-level lumbar fusion.The records indicate that this patient presents with a history of spinal stenosis of the lumbar region with neurogenic claudication and lumbar radiculopathy. With regard to the requested Ztildo patches, medical literature has not demonstrated consistent or reliable benefit of lidocaine patches for post operative pain control, and findings across studies remain inconclusive. This patient’s records do not document that the patient has exhausted the available therapies for pain relief that are well-supported in the medical literature. Accordingly, the requested Ztildo patches are not medically necessary for the treatment of this patient. Addressing the requested multi-level fusion, the patient has stenosis, spondylolisthesis, and scoliosis. Currently, the patient is symptomatic with progressive worsening of symptoms. The patient has reported attempting conservative measures, but the symptoms persist. One group of researchers conducted a “trial involving patients with symptomatic lumbar stenosis that had not responded to conservative management and who had single-level spondylolisthesis of 3 mm or more.” The authors reported that “Successful fusion was achieved with certainty in 86 of 100 patients (86.0%) who had imaging available at two years.” In this case, the proposed L1-5 decompression and fusion with interbody placement is indicated for the treatment of this patient’s spinal stenosis of the lumbar region with neurogenic claudication and lumbar radiculopathy (Yavin, et al.; Karlsson, et al.). Therefore, the requested multi-level fusion is supported as medically necessary for the treatment of the patient. Given these findings, the requested multi-level lumbar fusion is medically necessary for this patient, while the requested Ztildo patches are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary and the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46359

4. Upheld 2025 · Medical necessity · age 11–20 Jaw surgery · Bones, joints and muscles The physician reviewer found that the parent of a patient has requested authorization and coverage for immediate scheduling of orthognathic surgery. The patient’s provider agrees that the patient requires the requested surgery. However, the surgeon should…

   The physician reviewer found that the parent of a patient has requested authorization and coverage for immediate scheduling of orthognathic surgery. The patient’s provider agrees that the patient requires the requested surgery. However, the surgeon should determine the timing of the surgery based on scientific factors and specific criteria. This criteria includes whether or not the patient has stopped growing, as change in skeletal growth after orthognathic surgery may result in relapse. In this case, the patient’s provider has noted that it is recommended to obtain a computed tomography (CT) scan in one year to determine if the patient has ceased growing. At that point, the provider could compare previous radiographs and CT scans to determine if the patient is appropriate for the surgery, which is a reasonable and appropriate course of treatment. Overall, it is a standard of care for the treating surgeon to determine that the patient’s growth has ceased prior to surgery. Attempts to surgically intervene prior to ensuring the completion of skeletal growth could result in relapse. For patients under 18 years of age, there is limited evidence for routine orthognathic surgery in actively growing individuals. For these reasons, the requested immediate scheduling of orthognathic surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in oral facial and maxillary surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46341

5. Overturned 2025 · Medical necessity · age 51–64 Laminectomy · Bones, joints and muscles The physician reviewer found that a patient has requested authorization and coverage for left-sided laminectomy surgery with nerve decompression performed at L4-L5 and L5-S1. In this case, the patient has left lower extremity pain with an electromyography…

   The physician reviewer found that a patient has requested authorization and coverage for left-sided laminectomy surgery with nerve decompression performed at L4-L5 and L5-S1. In this case, the patient has left lower extremity pain with an electromyography (EMG) confirming severe left L5 radiculopathy. While the patient’s magnetic resonance imaging (MRI) does not report any evidence of nerve compression on the left at L4-5 or L5-S1, it does not comment on the lateral recess, which can cause compression. The patient has also already failed multiple types of conservative management and has progressively worsening and disabling left lower extremity symptoms. Thus, the next step would be to decompress the nerves, as the EMG confirmed the left L5 severe radiculopathy. Given these findings, the requested left-sided laminectomy surgery with nerve decompression performed at L4-L5 and L5-S1 is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46329

6. Upheld 2025 · Medical necessity · age 51–64 Spinal fusion · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for exploration spinal fusion procedure; and laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for exploration spinal fusion procedure; and laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar procedure. One group of authors notes that, “Posterior spinal decompression is one of the most common surgical procedures to release neural structures when nonoperative treatment has failed and is usually the procedure performed for degenerative conditions such as spinal stenosis, especially in middle-aged and elderly patients.” While the patient has been noted to have tried nonoperative treatment, significant spinal stenosis at the requested surgical level is not evident. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated the following at L3-4: disc of normal height, mild circumferential bulging and bilateral facet arthropathy with hypertrophy of the capsular ligaments, and moderate degree of central and foraminal stenosis. The MRI demonstrated at L4-S1 solid anterior/posterior fusion with graft, pedicle screw, and rod fixation. There have been posterior laminectomies and intraforaminal osteophyte formation resulting in moderate degrees of bilateral foraminal stenosis at L5-S1. A more recent MRI study of the lumbar spine was noted to show progressive L3-4 facet arthropathy with questionable facet cyst. However, a formal study with a radiologist’s read was not provided for review to corroborate these findings. Moreover, the examinations provided for review provided no objective musculoskeletal findings to corroborate significant neurological deficits to support the requested surgery. Overall, there are limited large-scale, long-term studies supporting the safety and efficacy of the requested surgery in this patient’s clinical setting. Given these findings, the requested exploration spinal fusion procedure; and laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar procedure are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46267

7. Overturned 2025 · Medical necessity · age 21–30 Jaw surgery · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for arthroscopic temporomandibular joint (TMJ) surgery for the enrollee’s left side of the jaw. In this case, the patient was…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for arthroscopic temporomandibular joint (TMJ) surgery for the enrollee’s left side of the jaw. In this case, the patient was diagnosed with left-sided TMJ dysfunction confirmed by magnetic resonance imaging (MRI). The record confirmed that the patient attempted the conservative treatment approach without success. As such, the requested arthroscopic TMJ surgery for the patient’s left side of the jaw is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in oral, facial, and maxillary surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46246

8. Overturned 2025 · Medical necessity · age 51–64 Arthroscopy · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for major arthroscopic synovectomy. Arthroscopic synovectomy is an effective treatment for recurrent synovitis of the knee and improves…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for major arthroscopic synovectomy. Arthroscopic synovectomy is an effective treatment for recurrent synovitis of the knee and improves patients’ functional status and quality of life. In this case, the patient has a history of recurrent synovitis with persistent left knee effusion. The literature supports the use of arthroscopic synovectomy in this clinical scenario. All told, the major arthroscopic synovectomy was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46226

9. Overturned 2025 · Medical necessity · age 51–64 Other · Feet The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a bunionectomy. The medical literature and submitted documentation support the medical necessity of the bunionectomy. Based on the medical…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a bunionectomy. The medical literature and submitted documentation support the medical necessity of the bunionectomy. Based on the medical records, this patient was suffering with a painful right side bunion deformity including right hallux valgus. Hypermobility of the first tarsometatarsal (TMT) joint was noted on physical examination with lateral deviation of the right hallux. Pain was also noted to the bunion deformity. The patient underwent a Lapidus-type bunionectomy. A bunionectomy is standard treatment when a patient has failed conservative treatments for bunion pain. Moreover, in this case, the patient was noted to have a painful bunion with osteoarthritic changes to the joint, a lateral deviation of the hallux, and hypermobility of the first TMT joint. In this patient’s clinical setting, the medical literature advises that the most appropriate treatment is a Lapidus-type bunionectomy. Therefore, the bunionectomy was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is a licensed D.PM., board-certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46222

10. Upheld 2025 · Medical necessity · age 51–64 Hip replacement · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right total hip replacement surgery. Hip osteoarthritis is a highly prevalent and disabling condition. Education, exercise, and…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right total hip replacement surgery. Hip osteoarthritis is a highly prevalent and disabling condition. Education, exercise, and weight loss are the cornerstones of management, complemented by nonsteroidal anti-inflammatory drugs, corticosteroid injections, and adjunctive medications. For patients with advanced symptoms and structural damage, total joint replacement effectively relieves pain. Total hip arthroplasty has shown great success in relieving joint pain and disability in the treatment of end-stage degenerative joint diseases and trauma. In this case, the patient is being treated for right hip atrophies and calcification of the hip. The patient presents with right hip pain, located at the hip, groin, and buttock. The patient has associated symptoms including limping, falling, stiffness, pain at night, buckling, low back pain, and instability. The patient’s symptoms are worsened by sports, startup, getting into/out of the car, putting on shoes, crossing legs, and sitting. The patient’s right hip exam revealed that the patient has an antalgic gait, decreased muscle strength with straight leg raise, weakness, and stiffness. The patient is noted to have a positive straight leg raise test, range of motion of 0-100 degrees, internal rotation of 0 degrees, quadricep atrophy, and is negative for instability. The patient’s provider documented that the patient’s X-rays shows Tönnis Grade 2, moderate narrowing of the joint space (less than 2 mm), definite osteophytes, subchondral sclerosis, and possible deformity of the femoral head. However, the radiologist interpretated the X-rays as showing mild right hip joint osteoarthrosis with acetabular osteophytic spurring with preserved joint space. In addition, the magnetic resonance imaging (MRI) of the patient’s right hip reports mild-to-moderate osteoarthritis changes of the right hip, and non/minimally displaced tear of the lateral acetabular labrum with fraying of the margin more dorsally. The patient’s formal diagnostic imaging studies do not demonstrate, severe, end-stage right hip osteoarthritis to support a total hip arthroplasty. Additionally, there are other plausible causes of the symptoms and findings reported, as demonstrated on the patient’s diagnostic imaging studies as well as the subjective complaints of the right hip and lower back. Overall, there are limited large-scale, long-term peer-reviewed studies showing the safety and efficacy of the requested right total hip replacement surgery in this patient’s clinical setting. Therefore, the requested right total hip replacement surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46190

11. Overturned 2025 · Medical necessity · age 41–50 Arthroscopy · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for hip arthroscopy with the removal of a loose body. In this case, the patient was being treated for chronic and debilitating left hip pain…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for hip arthroscopy with the removal of a loose body. In this case, the patient was being treated for chronic and debilitating left hip pain. The record establishes that after exhausting conservative treatment modalities, the patient underwent a left hip arthroscopy, labral tear repair, pincer osteochondroplasty, cam osteochondroplasty, chondroplasty of the acetabulum, multiple loose body removals, and capsular repair. The addition of loose body removal during arthroscopic labral repair was medically indicated to improve the potential for a better return to functionality and plausible prevention of future joint damage. As such, the hip arthroscopy with removal of loose body was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service was medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46182

12. Upheld 2025 · Medical necessity · age 51–64 Knee replacement · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for immediate scheduling of previously approved right knee surgery. Clinical guidelines for knee arthroscopy support surgical…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for immediate scheduling of previously approved right knee surgery. Clinical guidelines for knee arthroscopy support surgical intervention when there are persistent mechanical symptoms such as locking, catching, or functional limitation, or when there is confirmed structural pathology such as a meniscal tear that correlates with symptoms. Urgent or immediate surgical scheduling is generally reserved for cases with acute mechanical obstruction, inability to bear weight, or evidence that delay would result in significant clinical deterioration.In this case, diagnostic imaging does not demonstrate a meniscal root tear or other acute structural pathology requiring urgent intervention. While the patient reports pain and swelling, the records do not document mechanical symptoms such as locking or catching, nor do they demonstrate inability to bear weight. Additionally, there is no documentation establishing that delay in surgery would result in significant progression of pathology or adverse clinical outcome. Based on the absence of urgent clinical indications, immediate scheduling of the approved procedure is not supported by current guidelines.Therefore, the requested immediate scheduling of the approved right knee surgery is not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested service is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-46120