Magnetic Resonance Imaging Of The Knee denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s patellar contusion. A review of the record indicates that the enrollee has been diagnosed with acute patellar contusion, right knee. The enrollee was seen on 10/9/18, after slipping and falling directly on the right knee. The provider reported the enrollee previously had an arthroscopy with trimming of a discoid lateral meniscus of the right knee a year ago with good result. The enrollee was seen on 10/23/18, with reported worsening of right knee pain. The provider is recommending MRI of the right knee.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the middle spine and/or right knee. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain, for an adult patient with initial radiographs demonstrating degenerative changes, an MRI may be appropriate as the next imaging examination, if the patient's symptoms are not explained by the radiographic findings. In this case, the patient’s pain persists despite conservative management and were not explained by radiographic findings. Therefore, an MRI is appropriate, and he may be a surgical candidate.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the patient’s left knee patella injury. The submitted documentation does not support the medical necessity of the requested services. Autologous chondrocyte implantation is a technique that was developed in 1994 to treat cartilaginous defects in various joints, including the knee. It has been performed for both the tibiofemoral cartilage and the patellofemoral cartilage. The procedure involves a two-step surgery. Following implantation, there is a period of restricted weight bearing for up to eight weeks.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee.The American College of Radiology guidelines state that MRI is indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. It is not indicated before complete physical examination and radiography, or for the following conditions: severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. (American College of Radiology). Matar and colleagues noted, “The management of patients with knee pain is non-operative both for degenerative meniscal tears and degenerative joint disease in its initial stages. Magnetic resonance imaging has little added value in the management of middle-aged and elderly patients with degenerative disease.

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 Magnetic Resonance Imaging Of The Knee, then check the rights and deadlines that apply to your plan.