Lateral Epicondylitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment with a pain management specialist and either Dilaudid or morphine. The Centers for Disease Control and Prevention (CDC) guidelines state that, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.” Similarly, the Federation of State Medical Boards guidelines noted that, “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 objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.” In addition, the American Socie…

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma injections (CPT Code 0232T). Findings: The physician reviewer found that platelet-rich plasma is a promising treatment modality with substantial evidence of safety. Houck and colleagues reported that the results of their systematic review of overlapping meta-analyses suggest that corticosteroid injection improves functional outcomes and pain relief for lateral epicondylitis in the short-term, while autologous blood and platelet-rich plasma are the most effective treatment options in the intermediate-term. Arirachakaran and colleagues provided additional results indicating that platelet-rich plasma injections can be effective in the management of chronic lateral epicondylitis. This patient presented with persistent left lateral elbow pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) red light therapy machine for home use, (2) ultrasound machine for home use, and (3) cold therapy unit for home use. There is limited evidence in current medical literature supporting the use of red-light therapy, also referred to as low-level laser therapy (LLLT). Childress and Beutler report regarding the management of chronic tendon injuries, “Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.” However, Baktir and colleagues report regarding the short-term effectiveness of LLLT, “LLLT p…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral elbow platelet-rich plasma injections. Researchers conclude, “In patients with tendinopathies, a trend towards pain reduction and functional improvement from baseline was observed after ultrasound-guided platelet-rich plasma injections, but in the majority of the comparisons, the effect size was comparable to that observed in control groups.” The findings from this study were not conclusive of significant benefits over the control group. Researchers note, “Medial elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. Causes include medial epicondylitis, ulnar neuritis, ulnar collateral ligament injury, flexor pronator strain, or snapping medial triceps.

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