Orthopedic Procedures denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement for selective percutaneous myofascial lengthening (SPML) of the bilateral adductor/hip, bilateral hamstring, and bilateral leg/ankle/gastrocnemius with alcohol nerve block. Researchers explain, “Spastic cerebral palsy can be subcategorized based on the clinical picture and it usually leads to contractures that will need to be surgically released. SPML is one method that is used to release some of the contractures. SPML has many benefits such as being very quick, less invasive, and leading to faster recovery.” Researchers conclude that studies support the safety of the minimally invasive SPML release of the lower extremities based on the low complication and low reoperation rates.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthognathic surgery consisting of: midface reconstruction, LeFort 1 maxillary osteotomy, three segments, with autogenous local graft-advancement with clockwise occlusal plane rotation ; mandibular reconstruction, bilateral sagittal osteotomies of the mandibular ramus with rigid internal fixation-setback with counter clockwise occlusal plane rotation; and interocclusal surgical guide.At issue in this case is whether the requested orthognathic surgical services are medically necessary to treat the patient’s medical condition. In addition, does the patient’s severe malocclusion constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease?

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided. Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness.

Physician 1: The patient is a 51-year-old man with hip pain secondary to arthritis. He underwent metal-on-metal hip resurfacing in August 2004. The patient has requested reimbursement for the procedure at issue. The Health Plan has denied the patient’s request indicating the procedure at issue is considered experimental.Metal-on-metal hip resurfacing is an experimental procedure without proven efficacy. The current standard of care for the patient’s condition is a total hip replacement. This is the gold standard that all other treatments must be compared to. Metal-on-metal total hip resurfacing has not been effective and is out of favor given the extremely poor results of this technique.

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 orthopedic procedures, then check the rights and deadlines that apply to your plan.