Total Knee Arthroplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: An enrollee requested knee replacement surgery without the requirement to first quit smoking for treatment of his left knee degenerative joint disease. Findings: The physician reviewer found that the requested total knee arthroplasty at the left knee is supported as medically necessary for treatment of this patient’s advanced degenerative osteoarthritis. Imaging has been obtained which confirm advanced changes. There has been a trial and failure of treatment with standard therapies. The patient’s BMI and weight is not a contraindication to surgery. According to the medical literature, obesity does provide a greater risk of perioperative complications but the studies quoted describe morbid obesity. This patient’s BMI is not considered morbidly obese.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a knee replacement surgery. The submitted documentation does not support the medical necessity of the requested service. In a study of the appropriateness of total knee arthroplasties (TKA) in the United States, Riddle and colleagues found that the risk/benefit for TKA favored patients with intense or severe symptoms of knee osteoarthritis, who were at least 55 years old, had limited mobility, and had a body mass index (BMI) under 40 kg/m2. The authors noted that outcomes were much less favorable for patients with slight or moderate symptoms and functional loss, making the procedure not appropriate. Ferket and colleagues reported that the current practice of TKA in a recent U.S.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral to a tertiary level of care for an evaluation of the left knee, possible repair of the left knee medial patellofemoral ligament, and/or left knee replacement surgery. Researchers note, “A differentiated indication is decisive for a good outcome. Pain, limitations in quality of life because of osteoarthritis, radiological confirmation of osteoarthritis and inadequate response to conservative treatment should be reported.” Researchers conclude, “Based on the current literature available to date, a multidisciplinary and a multimodal approach with a key focus on exercise, weight loss and pharmacological pain management would be the most appropriate.” Researchers explain that the risk/benefit for total knee arthroplasty (TKA) favors patients who have intense or severe symptoms of kne…

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