Joint Problem Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Nalu Neurostimulation System. There are a number of treatment modalities available to treat challenging chronic pain syndromes. First line strategies generally involve pharmacotherapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, antiepileptics, and antipsychotic or antidepressant agents, followed by invasive procedures including injections with longer acting anesthetics and corticosteroids, depending on the location or anatomic target. When these techniques yield results, ablative procedures, which carry the risk of a permanent neurological deficit or deafferentation syndromes, may be pursued. If persistent structural problems, surgical intervention may be appropriate.

The parent of an enrollee has requested authorization and coverage for a treatment plan which includes: 1) open reduction of the left knee with a ligament reconstruction and Judet quadricepsplasty; 2) open reduction of the right hip with insertion of a suture tether to hold the joint in place while it heals; 3) bilateral serial casting of the feet; 4) post-surgical hospital admission; and 5) post-surgical physical therapy.Regarding open reduction of the left knee with a ligament reconstruction and Judet quadricepsplasty, the patient presents with arthrogryposis and possible Larson’s syndrome with congenital left knee dislocation that has caused a knee extension contracture. She has been treated conservatively with serial casting and physical therapy with persistent pain and inability to bear weight. Clinical findings have documented left knee range of motion as 0-60 degrees.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for posterior sacroiliac joint fusion procedure. Researchers explain, “The sacroiliac joint may be a primary source of pain in patients complaining of low back and/or buttock pain. Nonsurgical treatment of sacroiliac joint pain typically includes structured core and pelvic muscle flexibility and strengthening; pharmaceutical management through oral and injectable medication; and ablation procedures. For patients who do not improve with comprehensive, nonoperative treatment, surgical fusion of the sacroiliac joint is an option with overall good reported outcomes and high patient satisfaction. Minimally invasive surgery (MIS) approaches have been shown to have lower morbidity and earlier recovery than traditional open approaches.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left ankle. MRI is an imaging test that globally evaluates all anatomic structures, including ligaments, tendons, cartilage and bone. Most studies have shown that MRI is highly accurate for the evaluation of ligament, tendon and osteochondral abnormalities. MRI can identify synovitis and impingement lesions, which can contribute to patient symptoms. The American College of Radiology (ACR) appropriateness criteria for chronic ankle pain notes that radiograph of the ankle is the most appropriate initial imaging study. Researchers report regarding the evaluation of tarsal tunnel syndrome, “Plain radiographs of the ankle and, possibly, the foot are the initial imaging study of choice.

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 joint problem pain, then check the rights and deadlines that apply to your plan.