Osteoarthritis Of The Right Knee 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 Euflexxa injections in the right knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis, gastroesophageal reflux disease, degenerative joint disease and peripheral vascular disease. A visit note reported the enrollee presented with right knee pain. The enrollee reported previous left knee viscosupplement injections provided excellent results and previous right knee cortisone injections did not work.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of the right knee. The patient reported right knee pain associated with crepitation and stiffness. The provider noted the patient had moderately responded to a corticosteroid injection in the past with a limited duration. Physical examination findings included mild right knee valgus alignment. Tenderness to palpation was noted over the right knee lateral and patellofemoral compartments. There is no documentation of past relief from viscosupplementation injections. The patient has requested authorization and coverage for Euflexxa injections in the right knee only. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for arthroplasty, patella; without prosthesis, with the approved arthroplasty, knee, condyle, and plateau; medial or lateral compartment. A researcher explains, “Patellofemoral arthroplasty remains controversial, primarily due to the high failure rates reported with early implants. Several case series have been published over the years, which describe the results with various first- and second-generation implants. First-generation resurfacing implants had relatively high failure rates in the medium term. Second-generation implants, with femoral cuts based on total knee arthroplasty (TKA) designs, have yielded more promising medium-term results.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Zilretta injection in the right knee. The records indicate that this patient is being treated for osteoarthritis of the right knee and pain in the right knee. The patient’s right knee pain was improved by nearly 100% with a Zilretta injection and lasted almost three months. The patient reported that the benefits of the Zilretta injection are gradually wearing off. She has noticed more burning pain over the medial aspect of her knee without radiation. Her pain is worse with prolonged walking and standing and better with sitting and rest. Physical examination of the right knee revealed a small effusion with a range of motion from 0-120 degrees with guarding and crepitus. The knee is unstable with 1+ laxity with valgus stress at 0, 30, and 90 degrees and the patellar grind is positive.

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