Ankle Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 55-year-old male with bilateral ankle arthritis. He underwent left ankle debridement is 2002. The patient has been evaluated by multiple providers who have recommended ankle arthroplasty over fusion. The Health Plan indicates there is insufficient scientific evidence supporting the safety and efficacy of the requested procedure. Therefore, the Health Plan has determined the requested procedure is considered experimental. The standard of care for the surgical treatment of severe osteoarthritis of the ankle joint is fusion therapy. This is clearly and thoroughly supported in the literature. Additionally, the results of ankle fusion are very good for pain relief and restoration of function.

The patient has requested authorization and coverage for a Synvisc-One injection in the right ankle. Researchers reported that intra-articular hyaluronic acid (HA) administration can significantly reduce pain for patients with ankle OA. The authors also noted that locally injected HA treatment is an effective treatment for OA based on its effects of patient’s pain, function and patient global assessment. In terms of safety, it has also been shown that there are no statistically significant negative side effects in patients receiving injection treatment. Furthermore, the patient has a history of benefit from a prior viscosupplementation injection to the ankle. The medical evidence supports the requested service in this clinical setting.

Where the denial was upheld

A 61-year-old male enrollee has requested total ankle replacement with the STAR ankle system for treatment of his arthritis of the right ankle. Findings: Two physician reviewers found that there are now a significant number of peer-reviewed publications substantiating the use of a total ankle replacement in patients with end-stage ankle osteoarthritis, post-traumatic arthritis, and rheumatoid arthritis who have failed exhaustive conservative treatment. The Scandinavian Total Ankle Replacement (STAR) prosthesis is a 3-piece mobile bearing, porous-coated, unconstrained device designed for uncemented implantation. The stability of the prosthesis is provided by its anatomic shape as well as the patient's inherent ligamentous stability.

A 53-year-old male enrollee has requested coverage for Orthovisc injections for treatment of the his anterolateral ankle pain after an inversion injury. Findings: Three physician reviewers found that the patient suffers from ongoing foot and ankle pain. He had a talonavicular fusion which is noted to have progressed to nonunion. The patient’s provider has recommended Orthovisc injections for ankle osteoarthritis (OA) as demonstrated on magnetic resonance imaging (MRI). The records indicate that he has also undergone a course of physical therapy and anti-inflammatory drugs. The peer reviewed medical literature including case series and clinical trials does not currently support the long-term safety and effectiveness of viscosupplementation for ankle OA.

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 ankle osteoarthritis, then check the rights and deadlines that apply to your plan.