Right Knee Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis and left knee pain with moderately advanced arthritis. On 10/23/19, the patient received a right knee steroid injection. The provider recommended physical therapy, focusing on strength and range of motion of the lower extremities. The patient reported being unable to ambulate due to bilateral knee pain. The patient was noted to be severely deconditioned and morbidly obese. The patient has received viscosupplementation injections in the past, with good results. Physical examination findings included tenderness over the knee medial and lateral joint lines. Left knee steroid injection was administered. The patient has requested authorization and coverage for Euflexxa injections in both knees.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Synvisc-One injection and related services and prospective authorization and coverage for Euflexxa/Synvisc injection services for treatment of the enrollee’s knee pain. Findings: The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. This patient presents with chronic right knee pain. Clinical examination findings are consistent with the diagnosis of right knee osteoarthritis. The patient reported that reasonable conservative treatment, including medications, activity modification, and exercise have failed to provide adequate symptom relief. It was noted that prior viscosupplementation injections had provided significant sustained relief for six months.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right knee surgery, including allograft cartilage treatment for chondral defects in the patellofemoral compartment with the approved procedure. This patient is being treated for right knee pain and right knee primary osteoarthritis. He presented with right knee pain and swelling. The patient’s physical examination demonstrated trace effusion and crepitus with range of motion. Imaging revealed a 2 cm grade 4 trochlear lesion with intra-articular debris and synovitis. The patient has been treated with arthroscopy, viscosupplementation, physical therapy, activity modification, and weight loss. The provider has recommended right knee surgery including allograft cartilage treatment for chondral defects in the patellofemoral compartment.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injection to the right knee. This patient is being treated for right knee osteoarthritis. She presented with right knee pain that is rated at 0-5/10. She reports 100% relief for six months with her last right knee joint PRP injection. The patient indicated that the results from the PRP are wearing off and the knee is beginning to lock. The patient’s physical right knee examination revealed that the incisions are well healed, there is moderate effusion, and strength and sensation are intact. The right knee range of motion was 0-140 degrees. The patient has requested PRP injections.

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