Water Circulating Cold Pad With Pump denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for water circulating cold pad with pump for treatment of the enrollee, who is status post anterior cruciate ligament reconstruction. Findings: The physician reviewers found that the records support a portion of the device at issue. In this case, the patient underwent anterior cruciate ligament reconstruction. There exists significant evidence that the use of a motorized cooling pump after knee surgery improves pain outcomes in the early postoperative period. However, this case involved a purchase of the device at issue. The scientific literature supports a seven-day rental of the water circulating cold pad with pump. In sum, a seven-day rental of the device at issue was likely to have been more efficacious than other treatment options.

A 34-year-old female enrollee requested a water circulating cold pad with pump (E0218), pad for water circulating heat unit (E0249), and the Smart-Sling (L3670) for medical treatment of her left shoulder bursitis, impingement, and acromioclavicular (AC) joint arthritis. Findings: The physician reviewer found that based on the current medical literature, it was not medically necessary for this patent to receive passive water circulating cold pad with pump, water circulating heat unit as opposed to simpler applications of cold for post-operative shoulder care. Use of the Smart-Sling was likely to be beneficial given its design to assure some passive abduction, as well as versatility in allowing for beginning of range of motion in internal, external rotation at the discretion and supervision of the orthopedic surgeon.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested water circulating cold pad with pump for treatment of the enrollee’s medical condition. Findings: Two physician reviewers found that the water circulating cold pad with pump at issue was not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The standard of care post-operatively following a knee arthroscopy is the use of icepacks. There is a lack of sufficient support demonstrating cryotherapy results in increased efficacy when administered through a mechanized pump versus icepacks and ice bags. The study by researchers evaluated the use of cryotherapy following anterior cruciate ligament reconstruction. Six studies were reviewed, and some individual studies reported significant benefit.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a water circulating cold pad with pump (HCPCS E0218). The Health Plan has denied this request indicating that the device at issue was considered investigational for treatment of the enrollee’s symptoms related to his spine surgery. Findings The submitted documentation fails to demonstrate the superior efficacy of the device at issue in this clinical setting. There is a lack of recognized evidence based medical guidelines to support the use of water circulating cold pad with pump as an option for treatment of acute low back pain over the standard ice/cold packs. This patient underwent lumbar spinal surgery on 3/13/18 and was prescribed a cold compression unit for a three week post-operative use. The device at issue was prescribed pre-operatively.

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 Water Circulating Cold Pad With Pump, then check the rights and deadlines that apply to your plan.