Arthroscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the parent of a patient has requested reimbursement for either or both of the left knee arthroscopy surgeries: synovectomy (CPT code 29875) and/or chondroplasty (CPT code 29877). Authors in a study on plica syndrome noted, “Patients with plica syndrome will experience pain on the anterior aspect of the knee associated with clicking or popping. The anterior knee pain is a hallmark of plica syndrome. Pain can be brought on by rising from a chair, squatting, stairs, or other activities that load the patellofemoral joint. The history may include a twisting injury or blunt trauma, or there could be no history of injury or trauma.” Authors in another study on medial patellar plica syndrome noted, “Synovial plicae are thickenings of the synovial knee membrane; they are very frequent and often asymptomatic.

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).

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 surgical arthroscopy of the left shoulder with decompression and rotator cuff repair and coracoacromial ligament release for shoulder. Researchers explain, “Rotator cuff tear progression can be difficult to predict. Factors associated with tear enlargement include increasing symptoms, advanced age, involvement of two or more tendons, and rotator cable lesion. Nonsurgical treatment can be effective for patients with full-thickness tears.

Physician #1: The patient is a 61-year-old male with left knee chondromalacia. He is requesting reimbursement for an articular cartilage paste grafting procedure that was performed in November 2005. The Health Plan has denied coverage for the procedure at issue citing a lack of peer-reviewed literature supporting its use.There is no class I data to support the use of this procedure for knee osteochondral defects. The procedure remains experimental at this time. There is insufficient evidence that articular cartilage paste grafting is efficacious in this clinical setting. Furthermore, there were alternative standard procedures available for this patient’s condition. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

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