Left Knee Pain denials in California external review
In the California DMHC record, independent physician reviewers decided 14 published external-review cases involving left knee painand overturned the plan’s denial in 7.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for left knee pain
| Category | Decisions | Overturned |
|---|---|---|
| Magnetic Resonance Imaging Of The Knee | 3 | 0% |
What the reviewers wrote
Where the denial was overturned
A 61-year-old female enrollee requested authorization and coverage of knee replacement surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s left knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plan’s denial on the basis that the requested procedure is medically necessary.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for imaging services. Researchers state, “Back and neck pain are ubiquitous in today’s society, a common cause of disability, and a large burden to healthcare costs. When conservative management of low back or neck pain fails, magnetic resonance imaging (MRI) is the imaging modality of choice to assess for underlying abnormality. Knowledge of spine anatomy and imaging features of degenerative changes allow for appropriate reporting and directs appropriate patient management.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for suction assist lipectomy of the lower extremity. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients left knee pain and discomfort with genu valgus deformity and are not reconstructive in nature. This patient has well-documented evidence of primary chronic left knee pain associated with valgus alignment, mild lipodystrophy of the upper thighs, a history of morbid obesity, with constant trauma on the medial knees. However, the documentation does not indicate chronic intertrigo, dermatitis or injury and fails to adequately support that liposuction would directly improve the patients left knee condition.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 left knee pain, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY