Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for tramadol HCL. According to research, the use of a weak opioid in combination with an NSAID for pain control is indicated for mild to moderate pain and represents only the second step in the four-step ladder. Researchers have stated that medical necessity for chronic opioid therapy may be established on average moderate to severe pain (equal to 4, on a scale of 0 to 10) and/or disability. With regard to determining opioid dosage, researchers consider up to 40 morphine milligram equivalent (MME) as a low dose, from 41 to 90 MME as a moderate dose, and greater than 91 MME as a high dose. Medical literature states that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21.Findings: Three out of three physician reviewers found that left knee genicular nerve injection (CPT 64454) provided on 1/12/21 and left knee genicular nerve destruction (CPT 64624) provided on 2/09/21 were likely to have been more beneficial for you than any available standard therapy.Cankurtaran and colleagues compared the effectiveness of ultrasound-guided versus blind genicular nerve block for the treatment of osteoarthritis.

Where the denial was upheld

Physician 1: The patient is a 38-year-old female with a long-standing history of hip pain. She has been diagnosed with osteoarthritis. The patient’s physician recommended metal-on-metal hip surfacing, which the Health Plan has denied due to a lack of scientific evidence in peer-reviewed medical literature to support its efficacy.Metal-on-metal hip resurfacing is still in experimental/investigational studies. Short-term data is sparse, with no long-term prospective study establishing its effectiveness. In addition, the procedure’s risks are uncertain. Furthermore, there are other treatments available for this patient. At this time, metal-on-metal hip resurfacing cannot be recommended as there is very little data to warrant its general use.

Findings: The physician reviewer found that the patient has requested authorization and coverage for Zilretta (triamcinolone acetonide extended-release) injections. In a phase 3b, single-arm, open-label study, researchers report that safety data from the study suggests that patients can receive a second triamcinolone acetonide extended-release (TA-ER) injection without experiencing an increase in the incidence of adverse effects. The authors reported no substantial difference in the incidence of adverse effects between the first and second injections, except for slightly more arthralgia events after the second injection, which may indicate the return of osteoarthritis symptoms as part of the normal pathogenicity of osteoarthritis. The authors noted that patients were not permitted additional TA–ER treatments after the second injection through week 52.

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