Fracture denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 64-year-old woman who sustained a clavicle fracture in May 2004. At the time the patient was evaluated by an orthopedist union was not yet established and osteopenia was noted. A bone growth stimulator was recommended. The Health Plan indicates a bone growth stimulator is considered investigational for treatment of patients such as this patient. Bone growth stimulators are of proven efficacy and have been used with great success over the past twenty years. As the patient’s provider indicates, the only other treatment option for this patient who was at eight weeks from date of injury with no obvious callus formation or union, would have been surgery, plating and bone grafting of the fracture. Use of a bone growth stimulator was medically appropriate and necessary to attempt union of the patient’s fracture.

Physician 1The patient is a 64-year-old man with compression fracture of T9, T12, and L1-3. It has been recommended that the patient proceed with vertebroplasty and/or kyphoplasty because of the failure of conservative treatment. The Health Plan has denied authorization and coverage for the requested procedures indicating that vertebroplasty and kyphoplasty are considered investigational in nature.The patient has attempted conservative measures including rest, medication, and physical therapy, yet he has persistent pain. The submitted medical records demonstrate that the patient is a candidate for vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty have a proven place in the treatment of compression fractures. The procedure devices have been approved by the Food and Drug Administration and numerous reports have shown the efficacy of the procedures.

Where the denial was upheld

Physician 1: The patient is a 51-year-old man who sustained a right shoulder fracture from a fall off a six-foot ladder. Two months following the injury, x-rays demonstrated the shoulder has failed to heal properly. The patient’s physician has recommended the patient use the Dynasplint shoulder system. The Health Plan has denied coverage for the requested equipment on the basis it is considered investigational for treatment of the patient’s condition. The requested equipment has been used for years to treat joint immobility. The treatment of adhesive capsulitis includes medication, injections, and physical therapy. The Dynasplint will help with home therapy; failure to improve will necessitate surgery. The requested equipment is medically reasonable and the results are likely to be superior to those associated with any other therapy.

Physician 1: The patient is a 54-year-old male who has chronic back pain with disc degeneration and chronic multiple compression fractures due to a motor vehicle accident in May 2003. He is requesting authorization and coverage for a kyphoplasty. The Health Plan has denied this request citing the procedure’s lack of proven efficacy in this setting.Kyphoplasty is not likely to be effective in cases of multiple chronic compression fractures and multiple-level degenerative disc disease. Additionally, the patient’s injury occurred in 2003; a kyphoplasty performed three years from the time of injury is not likely to be beneficial. The procedure is considered experimental in this setting involving multiple chronic fractures and severe disc degeneration.

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