Knee Pain 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: An enrollee has requested authorization and coverage for genicular nerve block injection to the right knee. Genicular nerve blocks are typically utilized as diagnostic blocks before possible radiofrequency ablation but can also be considered therapeutic injections for knee pain. One randomized controlled trial compared genicular nerve blocks to placebo and concluded that genicular nerve blocks offer short-term pain relief. Another randomized controlled trial compared genicular nerve blocks to physical therapy. Genicular nerve blocks demonstrated increased physical capacity up to 12 weeks compared to physical therapy. A comparative study evaluated the effects of genicular nerve blocks with intraarticular steroid injection alone.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xtampza, Percocet, and Soma. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines do not provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers “should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.” The Federation of State Medical Boards (FSMB) guidelines state “continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objecti…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging of left heel and left knee. Findings: The physician reviewer found that The patient denied plantar fasciitis pain with palpation. Researchers explain, “Advanced imaging modalities, including computed tomography, magnetic resonance imaging (MRI), and dynamic fluoroscopic imaging, allow for a comprehensive evaluation of the knee joint. Compositional sequences for MRI can allow for an evaluation of the biochemical properties of cartilage, meniscus, and ligament that offer further insight into pathology that may not be apparent on conventional clinical imaging.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition. Findings: The physician reviewer found that the question of timing and necessity as to obtaining an MRI of the knee in the clinical setting of knee pain is critical in determining the appropriateness of the MRI. Medical literature and evidenced based studies indicate that an MRI is the most optimal means to evaluate an internal derangement; plain x-rays are of only limited value; but these medical studies show that an MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. (Miller) As noted in a paper by McCarty and colleagues, “An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment.

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