Amputation denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 19-year-old male who had a right hip disarticulation, which makes for a difficult gait that requires high-energy demand. The patient reports he is limited in activities of daily living with his current prosthesis. The patient has requested authorization and coverage for an Otto Bock C-leg to allow the patient to function at a higher level of activity. The Health Plan has denied the request on the basis that the requested equipment is considered investigational.Unfortunately, the patient’s gait will always be impacted and walking will take a great deal of energy due to the high level of amputation. The efficacy and safety of the Otto Bock C-leg remains unproven. The reliability of this prosthesis must be further investigated with regard to slippage of electrodes, etc.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for trans-radial myoelectric prosthesis with Coapt pattern recognition, TASKA hand prosthesis, and supplies. Per ODG’s criteria for the use of myoelectric upper extremity prosthetic devices, this patient meets the criteria for the requested equipment. The patient has sufficient neurological, myocutaneous, and cognitive function to operate the prosthesis effectively. He has an amputation or missing limb at the wrist or above. He is free of comorbidities that could interfere with maintaining the function of the prostheses. He retains sufficient microvolt threshold in the residual limb to allow proper function of the prosthesis, as he has had targeted muscle reinnervation (TMR) for prosthesis control.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for continued inpatient level of care services, or in the alternative, acute rehabilitation services.Admission to an inpatient rehabilitation facility is intended to provide intensive rehabilitation therapy in a resource-intensive inpatient hospital environment for patients who have complex nursing and rehabilitation needs and require the medical management of a rehabilitation physician at least three days per week. Patients are expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. This treatment plan includes ongoing treatment by physical and occupational therapies and speech-language pathology.

Nature of Statutory Criteria/Case Summary: The patient has a history of multiple chronic medical conditions, including arthropathy, for which he underwent a total left knee replacement in the past. This was complicated by an infection, and he ultimately underwent a left transfemoral amputation on 11/1/11. The patient underwent rehabilitation, including prosthetic ambulation training. He received a `preparatory` endoskeletal prosthesis in or around 2011 with an Ossur Symbionic (microprocessor-aided) knee, but he reportedly gained weight and could no longer use this prosthesis. Case management notes indicate that he received a replacement prosthesis in 2013 due to a weight gain of approximately 80 lbs. On 9/17/18, his provider noted that he is a current smoker of 11-20 cigarettes per day.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving amputation, then check the rights and deadlines that apply to your plan.