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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s knee pain. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis, essential hypertension, and morbid obesity. A visit note dated 11/2/18, reported the enrollee presented with bilateral knee pain, right more than left. The provider reported previous magnetic resonance imaging of the right knee revealed significant diffuse meniscus tear of the medial meniscus; and chondromalacia to the medial compartment, mild to moderate chondromalacia to the patella and a partial tear of the anterior cruciate ligament (ACL).

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the left knee. MRI is the current gold standard for the assessment of soft tissue, chondral, and bony pathologies of the knee joint. The American College of Radiology guidelines for chronic knee pain report that “MRI is indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. It is not indicated before complete physical examination and radiography, or for the following conditions: severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome.” In this case, the patient did not present with chronic knee pain. However, the records indicate that he sustained a twisting injury with noted immediate instability of the left knee.

Where the denial was upheld

Physician 1: The patient is a 24-year-old male that injured his left knee in October 2004 while playing soccer. Radiographic studies demonstrated a complete tear of the anterior cruciate ligament (ACL) and a bucket handle tear of the medial meniscus. The patient underwent left knee ACL reconstruction in October 2005. The operative report noted the medial meniscus was too damaged for repair and it was debrided with a near complete medial meniscectomy. There was also a posterior horn lateral meniscus tear that was debrided. As of May 2006 X-ray identified mild degenerative changes within the medial compartment however, the patient had no instability. The orthopedist noted the patient was currently asymptomatic. In September 2006 the provider noted the patient continued to do well with relatively no pain or instability, but he had occasional mild pain with descending stairs.

Physician 1: The patient is a 55-year-old female who underwent reconstruction of her right anterior cruciate ligament (ACL) and torn menial meniscus. The patient’s provider recommended a continuous passive motion (CPM) device for rehabilitation. The Health Plan has denied coverage for the equipment at issue on the basis it is considered investigational.There is insufficient evidence supporting the use of a CPM device in this case. There is no class I data demonstrating superior ACL outcomes with use of a CPM device as opposed to standard rehabilitation modalities. The use of CPM in this case was excessive and not medically warranted. Accordingly, I have determined the equipment at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

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 tear was denied, the published record says the denial is worth fighting.