Patellofemoral Arthritis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for right knee arthroscopy with lateral release (CPT codes 29873 and 29879).A review of the medical records provided for review reveals the medical necessity for the knee arthroscopy with partial medial and partial lateral meniscectomy and the necessity for arthroscopy with a lateral release (29873) due to the given mechanical symptoms, radiographic, and MRI findings. Additionally, the removal of loose bodies would be indicated with MRI and arthroscopic findings. However, the medical records, including physical examination and diagnostic tests, do not indicate the medical necessity for arthroscopy with surgical abrasion arthroplasty or multiple drilling of microfracture (29879).

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Supartz injection series to the left knee (2mL once a week for 3 weeks).Recent medical literature reveals a change in the current thinking regarding the beneficial effects of viscosupplementation in individuals with osteoarthritis of the knees. Peck and colleagues conducted a systematic review to discuss emerging evidence in the field of viscosupplementation for chronic knee pain secondary to osteoarthritis. They found that while previous studies have demonstrated variable results, more evidence is becoming available that is generally supportive of the benefit of viscosupplementation in the treatment of knee osteoarthritis. Acharya and colleagues conducted a prospective observational study in adults with knee osteoarthritis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Hymovis injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s osteoarthritis. At issue in this case is whether the requested treatment, Hymovis injections, is medically necessary for treatment of the enrollee’s medical condition.Hyaluronic acids (HA) are naturally occurring connective tissue materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic HA, also called viscosupplementation, can decrease osteoarthritis (OA) symptoms in some but not all patients; with sustained improvements in pain and functional outcomes, and few adverse events.

Physician 1: The patient is a 26-year-old female who is post anterior cruciate ligament (ACL) repair. She is experiencing pain and loss of motion and is unable to obtain relief with standard treatment modalities. Her provider has recommended she undergo an osteochondral allograft procedure. The Health Plan has denied this request on the basis that the requested procedure is considered investigational.There is no literature regarding the use of osteochondral allograft for focal defects of the knee after ACL reconstruction surgery. This patient now has established arthritis. Allografting the cartilage defects is not likely to be successful in this clinical setting. Given the lack of scientific data, the efficacy of the requested procedure remains unproven at this time and therefore, it cannot be recommended.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for patellofemoral arthritis was denied, the published record says the denial is worth fighting.