Knee Replacement denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee replacement surgery. In a multicenter longitudinal cohort study, colleagues concluded that the risk/benefit tradeoff for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility and a BMI less than 40. Li and colleagues conducted a national cohort sample study of 2,040 hip and 2,964 knee replacements, which looked at pain and function according to BMI status. Within this sample, 14 percent of hip and 25 percent of knee patients were severely or morbidly obese. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for left knee replacement and right knee replacement. In their multicenter longitudinal cohort study, Riddle and colleagues concluded that the risk-to-benefit ratio for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility, and a BMI less than 40. The authors found that surgical outcomes are less favorable for patients who have mild or moderate symptoms. Medical literature shows a national cohort sample study of 2,040 hip and 2,964 knee replacements evaluating pain and function according to BMI status. Within this sample, 14% of hip and 25% of knee patients were severely or morbidly obese.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for (1) immediate scheduling of a total knee replacement (TKR) for the right knee, or in the alternative, (2) an arthroscopic procedure for repair of tibia fracture, core decompression of marrow edema, preservation and debridement of anterior cruciate ligament and/or repair of the meniscus, and if so, (3) immediate scheduling of the arthroscopic procedure. The patient is requesting TKR surgery or arthroscopic surgery to be performed urgently with immediate scheduling. However, this is not supported as medically necessary as the patient was recommended to continue conservative measures examination, indicating that these conservative modalities have not been exhausted.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral total knee replacement surgery to be performed during the same surgical procedure, and admission to a skilled nursing facility (SNF) following surgery to provide 24/7 care for one to two weeks, or admission to an SNF following each unilateral total knee replacement surgery to provide 24/7 care for one to two weeks. Findings: The physician reviewer found that the records indicate that this patient is being treated for osteoarthritis of the bilateral knees. The patient was noted to have been approved for bilateral total knee replacement surgery originally scheduled, but this was canceled as he did not have postoperative care arranged.

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