Total Knee Replacement denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right knee replacement surgery. In a multicenter longitudinal cohort study, colleagues concluded that the risk/benefit tradeoff 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. Li and colleagues conducted a national cohort sample study of 2,040 hip and 2,964 knee replacements, which looked at pain and function according to BMI status. Within this sample, 14 percent of hip and 25 percent of knee patients were severely or morbidly obese. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total right knee replacement. Based on the recent medical literature with regard to total knee replacement in the presence of obesity, the prevalence of obesity and the utilization rate of total knee arthroplasty are increasing. The data suggests that the rate, as well as proportion, of total knee arthroplasties performed in the presence of obesity and morbid obesity has become more prevalent. Although the presence of obesity increases the risk of cardiovascular complications, with proper precautions, satisfactory in-hospital outcomes are observed after primary total knee arthroplasty. Researchers reported findings of increased mid- to long-term revision rates following primary total knee arthroplasty in the presence of obesity.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for (1) immediate scheduling of a total knee replacement (TKR) for the right knee, or in the alternative, (2) an arthroscopic procedure for repair of tibia fracture, core decompression of marrow edema, preservation and debridement of anterior cruciate ligament and/or repair of the meniscus, and if so, (3) immediate scheduling of the arthroscopic procedure. The patient is requesting TKR surgery or arthroscopic surgery to be performed urgently with immediate scheduling. However, this is not supported as medically necessary as the patient was recommended to continue conservative measures examination, indicating that these conservative modalities have not been exhausted.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total left knee replacement surgery. In a study of the appropriateness of total knee arthroplasties (TKA) in the United States, researchers 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. Researchers report, “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.

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