Meniscus Tear 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 magnetic resonance imaging (MRI). The Health Plan has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollee’s knee pain.Nationally recognized evidence based medical guidelines recommend MRI of the knee for patients with acute trauma to the knee or if suspected posterior knee dislocation or ligament or cartilage disruption. For children or adolescents with nontraumatic knee pain, MRI is the next study after nondiagnostic radiographs, if internal derangement is suspected. Medical literature reported an increasing number of individuals between the ages of 5-18 with a corresponding increase of acute and chronic injuries.

The enrollee is requesting authorization and coverage for Synvisc-One injection in the left knee. The patient’s pertinent diagnoses are degenerative joint disease of the knee, synovitis, meniscus tear, primary osteoarthritis of the left knee, and chondromalacia. The patient has been treated in the past with rest, several non-steroidal anti-inflammatory drugs, cortisone injections, braces, physical therapy and lifestyle changes; with minimal improvements in the underlying degenerative joint disease. With established efficacy of hyaluronic acid injections, and failure of other conservative treatments, including oral medication and corticosteroid injections, a repeated Synvisc-One injection is appropriate and medically necessary for this patient’s degenerative joint disease of the knee.

Where the denial was upheld

Physician 1: The patient is a 55-year-old female who underwent reconstruction of her right anterior cruciate ligament (ACL) and torn menial meniscus. The patient’s provider recommended a continuous passive motion (CPM) device for rehabilitation. The Health Plan has denied coverage for the equipment at issue on the basis it is considered investigational.There is insufficient evidence supporting the use of a CPM device in this case. There is no class I data demonstrating superior ACL outcomes with use of a CPM device as opposed to standard rehabilitation modalities. The use of CPM in this case was excessive and not medically warranted. Accordingly, I have determined the equipment at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for Euflexxa injections. Findings: The physician reviewer found that the enrollee has a history of bilateral knee pain and instability of the patella as well as subluxations and pain rated between 0/10 and 8/10. Patella grind and patella apprehension are both positive. Imaging is negative on x-rays for joint space narrowing. An MRI showed an anterior cruciate ligament (ACL) tear on the right knee, mild chondromalacia and patella alta. An MRI of the left knee showed a degenerative meniscus tear and mild cartilage loss. Treatments for her patella instability include activity modification, and steroid injections. She reports this has helped her, as has her physical therapy treatments.

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