Ankle Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 5-325 mg (one tablet every six hours) for treatment of the enrollee’s ankle pain.Findings: The physician reviewer found that the review of the submitted documentation supports the medical necessity for the request for Norco 5-325 mg (one tablet every six hours). In this case, the patient presents with chronic ankle pain after an injury occurring nearly six months ago with re-injury. The patient has also been treated for chronic nonmalignant pain including low back, pelvic, and abdominal pain with Norco. In terms of the patient’s medications, opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. The analgesic options for patients with chronic pain have steadily declined.

Findings: The physician reviewer found that The patient has requested authorization and coverage for bilateral molded arch supports. Custom molded tri-planar functional orthotics are recommended for the treatment of patients with ankle pain, subtalar joint valgus, subtalar joint varus, and pes planus. Custom molded functional orthotics have the ability to control abnormal biomechanics of the foot and ankle, allowing for foot and ankle biomechanical correction and pain relief. In this case, the patient sustained a significant right ankle fracture that required ORIF. The patient continues to have ankle pain post-operatively despite physical therapy. Physical examination demonstrates tenderness to the right ankle upon range of motion with a notable pes planus foot structure on the right side.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for urgent care services. The patient presented to urgent care for ankle pain. The patient described her pain as sharp, aching and constant for 2 days. There was no history of trauma. On exam, the patient’s vital signs were normal. The patient noted pain in the medial ankle, however, the exam was normal. Specifically, there was no tenderness to palpation, swelling, erythema or instability. There was normal range of motion and normal strength documented. X-rays were ordered and were normal. The patient was treated with an ACE wrap, and she was instructed to take over-the-counter Motrin, and to elevate and ice her ankle.The services at issue were not necessary for treatment of an emergency medical condition.

The patient has requested authorization and coverage for eight weeks of continued physical therapy. The records provided for review document that this patient has undergone extensive physical therapy consisting of 24 visits for her feet and ankles. The notes from her foot and ankle physical therapy suggest that the repeated objective examination findings of flexibility, joint integrity, muscle testing, palpation of soft tissues and pain levels do not reveal significant improvement from the start of physical therapy. The patient has not completed physical therapy for her low back pain. There is documentation of a lumbar x-ray revealing facet disease. However, there is no objective magnetic resonance imaging (MRI) or electrodiagnostic study to rule out a possible radicular etiology causing the patient’s back and ankle symptoms.

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