Degenerative Joint Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for methadone tablets with a quantity of 180 tablets every 30 days for chronic pain. Concerning this issue of whether clinicians should continue with opioid therapy for chronic pain, the Centers for Disease Control and Prevention (CDC) indicate that providers should carefully weigh the benefits and risks and exercise care when changing the opioid dosage. If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with synovial chondromatosis and degenerative joint disease. The patient reported left knee pain. The patient was noted to be status post open synovectomy for synovial chondromatosis. Physical examination findings included a mild left knee effusion and crepitation of the patellofemoral joint. An x-ray was noted to reveal significant synovial chondromatosis with joint space narrowing. A Celestone injection was administered to the left knee. The provider noted the Celestone injection did not provide the patient with pain relief. The patient has requested authorization and coverage for hyaluronan injections (CPT J7321) for the left knee. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for lumbar and neck epidural corticosteroid (steroid) injections and/or bilateral ankle arthroscopy and bilateral knee arthroscopy followed by rehabilitation and physical therapy (PT) services.Lumbar transforaminal injection of steroid (LTFIS) is a treatment for radicular pain. Steroids are believed to have a therapeutic effect due to their anti-inflammatory properties. Smith and colleagues concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. The authors indicated that there is a lack of high-quality evidence demonstrating their effectiveness in the treatment of radicular pain due to spinal stenosis.

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for arthroscopic surgery for the left knee. According to the medical record, the enrollee has a history of left knee pain, for which she had previous arthroscopic partial meniscus debridement. She presented for orthopedic evaluation as her left knee pain has been worsening. Orthopedic examination of the left knee showed pain, swelling, and decreased range of motion. The orthopedist diagnosed left knee osteoarthritis and degenerative joint disease. X-rays showed mild joint space narrowing. According to the medical literature, the majority of studies do not support the use of arthroscopic partial meniscus debridement (APM) with osteoarthritis, and even when there is no osteoarthritis.

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 degenerative joint disease, then check the rights and deadlines that apply to your plan.