Cold Therapy Unit denials in California external review

What the reviewers wrote

Where the denial was overturned

This patient is a 33-year-old male who underwent surgery on his right knee for anterior cruciate ligament (ACL) reconstruction and meniscectomy in August 2004. Postoperatively, his orthopedic surgeon prescribed a cold therapy unit, which he utilized for two weeks or so. The patient’s request for reimbursement was denied based upon the Health Plan’s determination that the Thermal Therapy Device was not medically necessary.The device in question is commonly prescribed after knee and shoulder surgery to help decrease postoperative swelling and alleviate pain. The device is superior to ice packs placed intermittently in that the cooling is continuous, it can be used around the clock and it is comfortable and efficient.

The patient is a 36-year-old male who underwent extensive surgery to his left knee, including ACL reconstruction and partial meniscectomy. Postoperatively he utilized a cold therapy unit as prescribed by his orthopedic surgeon. He is now requesting reimbursement for the rental cost of the device. The Health Plan denied his request based upon their determination that the cold therapy unit was not medically necessary following the patient’s surgery. A cold therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery. The cool water is encompassed in a pad that wraps around the knee and is incorporated in the post operative dressing. This device is extremely helpful in relieving postoperative pain and swelling.

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 cold therapy unit. Researchers state, “There is no consensus as to whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with bagged ice or ice packs. However, complications from cryotherapy, including skin irritation, frostbite, perniosis, and peripheral nerve injuries, can be avoided through patient education and reducing the duration of application.” Researchers report that continuous cryotherapy does not appear to offer significant benefits for total knee arthroplasty when compared with traditional cryotherapy such as with the use of an ice bag or gel pack.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a cold therapy unit. Kunkle and colleagues report, “There is no consensus as to whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with bagged ice or ice packs.” Thacoor and Sandiford report, “Cryotherapy has been shown to have some benefits but the severe lack of level 1 studies supporting its use make it difficult to reach a suitable conclusion. Further multicenter randomized controlled trials with representative populations and fair comparison of devices are needed.” In this case, the patient is a 51-year-old female with chondromalacia patellae, peripheral tear of the medial meniscus, and patellofemoral disorders of the right knee.

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 Cold Therapy Unit, then check the rights and deadlines that apply to your plan.