Custom Knee Brace denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving Custom Knee Braceand overturned the plan’s denial in 38.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Custom Knee Brace denials
| Category | Decisions | Overturned |
|---|---|---|
| Anterior Cruciate Ligament Tear | 11 | 54.5% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom knee brace. Findings: The physician reviewer found that the patient presents with extensive injuries that include ACL tear, lateral collateral ligament tear, posterolateral capsular avulsion and avulsion of the biceps tendon from its insertion into the fibular head. The patient’s recovery has been prolonged and limited by pain and persistent muscle atrophy. He has undergone autologous gracilis tendon grafts and autologous semi-tendinosis grafts. The combination of the original injury and multiple harvesting of hamstring tendon for reconstruction have contributed to a prolonged and limited recovery. His knee with weakened quadriceps and hamstring muscles are vulnerable to re-injury through his activities as a physical education teacher.
Nature of Statutory Criteria/Case Summary: An enrollee requested a custom knee brace for treatment of her medical condition status post anterior cruciate ligament (ACL) reconstruction with allograft. Findings: The physician reviewer found that it is medically necessary for this patient with stated XXX syndrome and clinical findings of generalized ligamentous laxity to have the protective benefits of a custom knee brace. This has been recommended for a period of one year after ACL reconstruction. The patient has XXX syndrome, which is characterized by a wide range of effects including variable musculoskeletal syndrome. Due to the documentation of a generalized ligamentous laxity combined with the stated XXX syndrome, it is prudent for this patient to have the benefit of ACL bracing during rehabilitation.
Where the denial was upheld
A 56-year-old male has requested a custom left knee brace for treatment of his left knee osteoarthritis. Findings: The physician reviewer found that the medical literature with respect to the clinical effectiveness of knee orthoses in the setting of knee arthropathy is limited. A Cochrane review in 2005, for instance, found limited evidence based on one study in a meta-analysis that supported bracing for knee arthritis. This was limited to subjects with medial knee involvement.
A 40-year-old female enrollee has requested a custom knee brace and lightweight material for treatment of her torn anterior cruciate ligament. Findings: The physician reviewer found that the requested brace is a functional brace that supports damaged ligaments. It is frequently used by individuals participating in sports after an injury. However, there is insufficient reliable evidence in the medical literature that supports the superior efficacy of this device in the postoperative period following ACL reconstruction in comparison to the use of a basic knee support such as a neoprene knee sleeve. Birmingham, et al. published the results of a clinical trial in 2008, concluding that, `A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Custom Knee Brace, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY