Osteoarthritis Of The Ankle denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a fitted shoe (orthotic boot) for treatment of his osteoarthritis of the left ankle. The physician reviewer found that a review of the literature reveals that for well selected patients, normal footwear is all that is needed following ankle fusion. However, articles also discuss several different types of shoe modifications, in-shoe orthoses, and ankle foot orthoses that are very commonly used for many patients following this procedure. Sirveaux and colleagues reported that modifying shoegear to increase the instep of the shoe improves the biomechanical abnormalities that occur.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection (HCPCS J7325) in the right ankle.In a review by Papalia and colleagues, the authors indicate, “Current evidence suggests that viscosupplementation for treatment of ankle osteoarthritis is a safe and effective method.” The authors also concluded that more randomized controlled trials are needed. Khlopas and colleagues state that viscosupplementation with hyaluronic acid has been shown to be a safe and effective method of treating osteoarthritis of the ankle. The authors reason that, “For patients who have moderate to severe disease, surgery may be indicated.

Where the denial was upheld

Physician 1: The patient is 62-year-old woman with arthritis of the ankle. She wishes to proceed with ankle replacement utilizing the Agility Total Ankle Arthroplasty device. The Health Plan has denied coverage for the proposed procedure indicating there is in sufficient evidence of its efficacy in the peer-reviewed literature.The recommended prosthesis has been approved by the Food and Drug Administration and there is growing support in the medical literature for total ankle arthroplasty in the scientific literature. Several articles have been published regarding the efficacy of the procedure in appropriately selected patients. Based upon the records provided, the patient is a good candidate for total ankle arthroplasty. The only other option in this case is arthrodesis, which is not likely to be as effective.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T). Findings: The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis.

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