Anterior Cruciate Ligament Reconstruction: when insurers say no, reviewers often say yes

Where the denial was overturned

A 51-year-old male enrollee has requested knee brace (CPT code L1845) and knee brace add-ons (CPT codes L2810, L2820, L2830, and L2850) for the treatment of his right knee, status post anterior cruciate ligament (ACL) reconstruction surgery. Findings: The physician reviewer found that the use of a medial unloader brace was medically necessary for this patient’s specific clinical situation. Although the medical records do not include a description of the patient’s knee in reference to genu vera or genu valga, the medical records do document chondroplasty of the medial femoral condyle. This patient, at age 51, is an outlier as far as anterior cruciate repair in patients. The duration of the instability in the knee is important to the development of degenerative osteoarthritis within the joint.

A 55-year-old female enrollee has requested an anterior cruciate ligament (ACL) knee brace for treatment of her medical condition status post ACL reconstruction surgery. Findings: The physician reviewer found that it is in the best interest of this patient to be fitted and use the knee orthotic as recommended by her treating provider. In general, it remains controversial as to whether orthotic bracing is needed after ACL reconstruction as part of the postoperative protocol, (Wright and Fetzer). However, the use of an orthotic for prophylaxis in patients who have undergone ACL reconstruction has been addressed through the article authored by Sterett and colleagues. These researchers addressed the issue of whether an orthotic prescribed by a treating physician would likely be effective in protecting patients from recurrent injury.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy at a facility that provides weight training, has machines that test joint strength, and has an AlterG Anti-Gravity Treadmill. The current medical literature related to rehabilitation after anterior cruciate ligament (ACL) reconstruction supports early weight bearing, early range of motion exercise, and closed kinetic chain activities. As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months. Rehabilitation following ACL reconstruction can require be prolonged. However, the entire rehabilitation process following ACL reconstruction does not require a formal therapy setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Elite Seat patient-controlled end range of motion stretching device. Mechanical devices for flexion and extension are recommended as an option in conjunction with continued physical therapy when six weeks of physical therapy alone has been unsuccessful in adequately correcting range of motion limitations secondary to postoperative arthrofibrosis within three months of major knee surgery. The goal is to address specific range of motion limitations that cause functional limitations. In this case, the patient is status post a right anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft in January 2020. At the time of the request for this device, the patient was five months status post ACL surgery.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for anterior cruciate ligament reconstruction was denied, the published record says the denial is worth fighting.