Knee Problem 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 bilateral Euflexxa injections for treatment of the enrollee’s chronic bilateral knee pain. Findings: The physician reviewer found that Evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.

Physician 1: The patient is a 35-year-old woman status post multiple surgeries on her left knee. She reinjured her knee in August 2005 and now has a large lesion in the cartilage of the left lateral condyle. The patient’s provider recommends autologous chondrocyte implantation to repair the defect. The patient’s request for authorization was denied by the Health Plan based on a determination that the procedure is experimental/investigational.Autologous chondrocyte implantation has been FDA approved for almost ten years. The procedure has been utilized extensively in both Europe and the United States. This patient is young and active and chondrocyte implantation offers her the best outcome. Successful implantation will cover the defect and prevent further deterioration thus avoiding traumatic arthritis and knee replacement. No long-term safety issues have been identified.

Where the denial was upheld

Physician #1: The patient is a 61-year-old male with left knee chondromalacia. He is requesting reimbursement for an articular cartilage paste grafting procedure that was performed in November 2005. The Health Plan has denied coverage for the procedure at issue citing a lack of peer-reviewed literature supporting its use.There is no class I data to support the use of this procedure for knee osteochondral defects. The procedure remains experimental at this time. There is insufficient evidence that articular cartilage paste grafting is efficacious in this clinical setting. Furthermore, there were alternative standard procedures available for this patient’s condition. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Physician 1: The patient is a 26-year-old female who is post anterior cruciate ligament (ACL) repair. She is experiencing pain and loss of motion and is unable to obtain relief with standard treatment modalities. Her provider has recommended she undergo an osteochondral allograft procedure. The Health Plan has denied this request on the basis that the requested procedure is considered investigational.There is no literature regarding the use of osteochondral allograft for focal defects of the knee after ACL reconstruction surgery. This patient now has established arthritis. Allografting the cartilage defects is not likely to be successful in this clinical setting. Given the lack of scientific data, the efficacy of the requested procedure remains unproven at this time and therefore, it cannot be recommended.

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