Osteoarthritis Of The Left Knee denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Synvisc-One injection to the left knee. The enrollee has moderate osteoarthritis of the left knee. An x-ray of the left knee showed left knee osteoarthritis with 2mm medial asymmetric joint space narrowing and mild to moderate degenerative changes to the medial compartment. On focused physical exam of the left knee, the enrollee had tenderness to palpation at the joint line but had full range of motion (0 degrees extension to 130 degrees flexion) and no joint instability. The record indicates the enrollee has been treated with ibuprofen and physical therapy for more than six months; and was now in the process of getting a knee brace. He received a left knee cortisone injection on this visit for refractory knee pain.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Durolane knee injections for their medical condition of knee pain. Findings: The physician reviewer found that The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s primary osteoarthritis of the left knee. The submitted documentation supports the medical necessity of the requested medication. There is significant current medial evidence supporting the use of viscosupplementation for management of osteoarthritis of the knees.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a computerized tomography (CT) scan of the left knee. The patient presented to her provider with severe degenerative osteoarthritis of the left knee. The treatment plan included a left knee arthroplasty. The provider requested pre-operative imaging to assess for both bone deformity and bone loss and for preoperative computer templating for robotic-assisted surgery. The detailed documentation failed to demonstrate evidence of any unusual bony anatomy of the left knee or any retained surgical hardware in her left knee. One study concluded that “Although previous results showed more outliers regarding posterior slope for CT-based patient-specific instruments (PSIs), no difference in revision rate or the outcome of patient-reported outcome measurements (PROMs) was found at 2-year follow-up.

Findings: The physician reviewer found that a patient has requested authorization and coverage for left total knee arthroplasty (TKA). The authors of a study state that “Pain, limitations in quality-of-life because of osteoarthritis, radiological confirmation of osteoarthritis, and inadequate response to conservative treatment should be reported. Moreover, medical history, clinical examination and radiographic findings need to be conclusive.” The authors concluded that “the patient’s level of suffering and discomfort defines the timing of an arthroplasty.” In this case, the patient reported to the provider severe left knee pain localized to the medial joint and patellofemoral joint with intermittent swelling and waking up at night. The patient’s range of motion was 2 to 125 degrees with pain and crepitus, and positive McMurray and patellar grind tests.

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