Coverage decision

Knee arthroscopy using debridement and lavage as a treatment for osteoarthritis of the knee is not covered.

This does not apply to the use of knee arthroscopy for diagnostic purposes.

L&I’s medical treatment guidelines for knee surgery are available at: http://www.Lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/KneeSurgery.pdf

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed knee arthroscopy using debridement and lavage for the treatment of osteoarthritis on August 15, 2008. Based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, the committee’s determination is that knee arthroscopy with debridement and lavage is not covered for patients where the only indication is osteoarthritis.

Complete information on this HTCC determination is available here: http://www.hta.hca.wa.gov/

How to request authorization for knee arthroscopy

For State Fund Claims

All requests for knee arthroscopy require prior authorization and are reviewed by L&I’s utilization review (UR) vendor (Qualis).

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact Qualis Health in any of the following ways:

• Web: Qualis Health’s preferred method of submitting UR requests is via a secure, internet application called iExchange. For more information or to schedule a training session, please go to the Qualis Health web page at http://www.qualishealth.org/cm/washington-landi/web-based_um_request.cfm.
• Phone: (800) 541-2894 (toll free) or (206) 366-3360
• Fax: (877) 665-0383 (toll free) or (206) 366-3378

For Crime Victims:

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact the Crime Victims’ Compensation Program's nurse consultant by fax to (360) 902-5333 or phone call to (360) 902-4896.

For Self-Insured Claims

For self-insured claims, contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

Health Care Authority's Health Technology Assessment Program site.

For more information:
Contact information.

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