Prosthesis denials in California external review
In the California DMHC record, independent physician reviewers decided 94 published external-review cases involving Prosthesisand overturned the plan’s denial in 51.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Prosthesis denials
| Category | Decisions | Overturned |
|---|---|---|
| Amputation | 55 | 49.1% |
| Stroke CVA | 4 | 25% |
| Auto Accident | 3 | 100% |
| Paralysis | 3 | 0% |
| Deformities | 3 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 64 | 53.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 30 | 46.7% |
What the reviewers wrote
Where the denial was overturned
Physician 1: The patient is a 46-year-old woman who is a right above-the-knee amputee status post a motor vehicle accident. She underwent an open reduction internal fixation procedure on the left knee. She is requesting reimbursement for a microprocessor-controlled knee for the right leg that she obtained for the stated purposes of improved stability and function. The Health Plan has denied the patient’s request on the basis that the prosthetic device at issue is investigational in this setting.Upon review of the submitted documentation including review of the patient’s functional status and her activity level, it is not likely the patient will experience superior results with a microprocessor-controlled knee.
Findings: The physician reviewer found that The patient requested authorization and coverage for a Ossur Rheo microprocessor knee and Ottoback Maverick Comfort AT prosthetic foot.Current literature regarding the benefits of microprocessor-aided prosthetic knees relative to prosthetic knees without microprocessor-aided control is largely mixed and based on small patient numbers with low-quality data. A study indicated that there is a lack of high quality evidence showing improvement with microprocessor-aided prosthetic knee devices on the risk of falls and gait parameters over prosthetic knee devices without computer control. Further, the studies promoting motor-processor controlled knees are of low quality.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has a history of multiple chronic medical conditions, including arthropathy, for which he underwent a total left knee replacement in the past. This was complicated by an infection, and he ultimately underwent a left transfemoral amputation on 11/1/11. The patient underwent rehabilitation, including prosthetic ambulation training. He received a `preparatory` endoskeletal prosthesis in or around 2011 with an Ossur Symbionic (microprocessor-aided) knee, but he reportedly gained weight and could no longer use this prosthesis. Case management notes indicate that he received a replacement prosthesis in 2013 due to a weight gain of approximately 80 lbs. On 9/17/18, his provider noted that he is a current smoker of 11-20 cigarettes per day.
Physician 1: The patient is a 24-year-old female who is status post right trans-femoral amputation following a motor vehicle accident in 2001. Her physician states the patient has used a wheelchair since the accident due to the fact that her limb is too short for a prosthesis. Her physician also indicates the patient underwent revision of the residual limb in October 2004 and has recovered well enough to allow her to use a prosthesis. The patient’s physician has recommended the patient receive an Otto-Bock C-leg prosthesis.There are no case-controlled, randomized studies demonstrating the superiority or improved functional outcomes of the Otto-Bock C-leg prosthesis compared to standard prosthetics.
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 Prosthesis, 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