Ligament Tendon Repair denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma (PRP) injections for the right knee. This patient sustained a right knee injury and was diagnosed with a grade 3 medial collateral ligament (MCL) tear, anterior cruciate ligament (ACL) tear, medial meniscus tear, and lateral meniscus tear. She underwent ACL reconstruction with medial and lateral meniscus repair. Surgical augmentation with PRP was given as the MCL and meniscal capsular junction were not repaired surgically. A subsequent PRP injection was performed to the posterior lateral corner ligaments including popliteus, arcuate ligament, popliteal fibular ligament, and fibular collateral ligament.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right biceps tenodesis as part of an approved right shoulder acromioplasty and rotator cuff repair surgical procedure. Findings: The physician reviewer found that Gottschalk and colleagues conducted a study to determine whether subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV superior labral anterior and posterior (SLAP) lesions. They concluded that biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

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 any or all of the components of the requested left shoulder surgical procedure including arthroscopy, shoulder, surgical, with rotator cuff repair; tenodesis for rupture of long tendon of biceps; and/or arthroscopy, shoulder, surgical, debridement, extensive, three or more discrete structures. Researchers report, “In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for medial patellofemoral ligament (MPFL) reconstruction.Findings: The physician reviewer found that “MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent lateral patellar dislocation.” Hopper and colleagues explain, “The MPFL is the main restraining force against lateral patellar displacement. It is disrupted after patellar subluxation or dislocation.

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 Ligament Tendon Repair, then check the rights and deadlines that apply to your plan.