Trans-femoral Amputation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient requested authorization and coverage for a Ossur Rheo microprocessor knee and Ottoback Maverick Comfort AT prosthetic foot.Current literature regarding the benefits of microprocessor-aided prosthetic knees relative to prosthetic knees without microprocessor-aided control is largely mixed and based on small patient numbers with low-quality data. A study indicated that there is a lack of high quality evidence showing improvement with microprocessor-aided prosthetic knee devices on the risk of falls and gait parameters over prosthetic knee devices without computer control. Further, the studies promoting motor-processor controlled knees are of low quality.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoskeletal knee/shin system with microprocessor control. There is a growing body of medical literature to support the use of microprocessor-controlled prosthetic knees for certain patient groups. Researchers note that the benefits of microprocessor-controlled prosthetic knees (MPKs) have been well established in community ambulators with a transfemoral amputation (TFA). The authors noted that a literature review suggests that limited community ambulators may also benefit from using an MPK in safety, performance-based function and mobility, and perceived function and satisfaction.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has a history of multiple chronic medical conditions, including arthropathy, for which he underwent a total left knee replacement in the past. This was complicated by an infection, and he ultimately underwent a left transfemoral amputation on 11/1/11. The patient underwent rehabilitation, including prosthetic ambulation training. He received a `preparatory` endoskeletal prosthesis in or around 2011 with an Ossur Symbionic (microprocessor-aided) knee, but he reportedly gained weight and could no longer use this prosthesis. Case management notes indicate that he received a replacement prosthesis in 2013 due to a weight gain of approximately 80 lbs. On 9/17/18, his provider noted that he is a current smoker of 11-20 cigarettes per day.

Physician 1: The patient is a 24-year-old female who is status post right trans-femoral amputation following a motor vehicle accident in 2001. Her physician states the patient has used a wheelchair since the accident due to the fact that her limb is too short for a prosthesis. Her physician also indicates the patient underwent revision of the residual limb in October 2004 and has recovered well enough to allow her to use a prosthesis. The patient’s physician has recommended the patient receive an Otto-Bock C-leg prosthesis.There are no case-controlled, randomized studies demonstrating the superiority or improved functional outcomes of the Otto-Bock C-leg prosthesis compared to standard prosthetics.

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 trans-femoral amputation, then check the rights and deadlines that apply to your plan.