M17.10 — Knee Osteoarthritis
Denied63F · procedure — Total knee replacement
Insurer Rationale
The requested knee replacement is not medically necessary until appropriate conservative treatment has been attempted and documented.
Reasoning Chain
This denial is clinically aligned. The patient is symptomatic but the conservative pathway has barely started, so replacement is ahead of the evidence and ahead of usual orthopaedic thresholds.
Reasoning Chain
Findings
Chronic knee pain, Antalgic gait, Reduced mobility, BMI 32
Diagnosis
Osteoarthritis (confirmed on imaging)
Assessment
Pre-arthroplasty suitability review — Conservative measures are incomplete, so arthroplasty is premature.
Guideline action
Complete structured conservative management before arthroplasty referral
Verdict
Denial aligns with osteoarthritis care standards because surgery should follow, not replace, conservative first-line care.
Clinical Evidence
NICE Guideline NG226 — Osteoarthritis in over 16s
Core treatments
Education, exercise, and weight management are the initial steps before joint replacement is considered.
BOA Guidance on Arthroplasty Thresholds (2024)
Timing of referral
Replacement decisions should follow documented failure of conservative measures and shared decision-making.