Chondromalacia denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient has requested reimbursement for knee and debridement/shaving of articular cartilage (chondroplasty), same or separate compartment. Researchers performed a systematic review of the role for arthroscopic meniscectomy in knees with degenerative changes. The authors reported that two randomized controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. The authors concluded that patients with symptomatic meniscal tears and degenerative changes in the knee might benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. This patient sustained a left knee injury. He felt a left knee pop with immediate onset of medial joint line pain. His symptoms were reported as constant with functional limitations in ambulation.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Synvisc injection series administered to the left knee. Evidence from randomized trials and current medical literature has revealed varied results, as viscosupplementation may relieve some knee pain in individuals with osteoarthritis. However, the evidence concerning which individuals may benefit from viscosupplementation is unknown. In an effort to establish a more effective treatment, different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents. However, guidelines from the leading experts indicate that confirmatory evidence is limited and not conclusive. As such, the leading experts do not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for torn meniscus surgery in the left knee. As noted in medical literature, “Indications for arthroscopic partial meniscectomy (APM) are traumatic tears with a clear history of mechanical symptoms, such as locking and catching, with joint-line pain or acute onset of symptoms that have failed nonsurgical treatment.” Moreover, clinical studies have shown, “recent studies have conclusively shown that outcomes after an APM [arthroscopic partial meniscectomy] are no better than the outcomes after a sham/placebo surgery.” In addition, “Meniscal repair is now being touted as a viable and effective alternative. Meniscal repair aims to achieve meniscal healing while completely avoiding the adverse effects of partial meniscectomy.

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