Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 65-year-old male who presented on 2/13/17 with continued right knee pain. The patient reported mixed results with platelet-rich plasma injections and viscosupplements did not help. He reported that the corticosteroid injection helped but the effect was somewhat transient. He reported pain along the anterior aspect. Right knee examination documented some patellar tilt, range of motion 2-130 degrees with some tightness and tenderness at extremes, and not a lot of increase in his Q-angle. X-rays of his knees demonstrated some arthrosis in the patellofemoral region, but not a lot of wear in the tibiofemoral aspects. Magnetic resonance imaging (MRI) was reviewed and demonstrated edema along the lateral trochlear area in combination with some arthrosis from the patellofemoral perspective. He was status post partial meniscectomy. The treatment plan included arthroscopic evaluation of his knee with lateral release and debridement. The patient did not want a knee replacement. The provider noted that to assist in his post-operative recovery and rehabilitation and mitigate post-operative complications associated with prolonged prescription pain medication and/or non-ambulation/non-weight bearing such as increased risk of deep vein thrombosis (DVT) formation, he would prescribe durable medical equipment to reduce pain, swelling, edema, mitigate the risk of DVT, and improve his range of motion and strength. The patient underwent right knee arthroscopy with debridement and lateral release on 2/22/17. There were no post-operative notes available for review. The medical records indicate that an intermittent limb compression device was provided from 2/22/17 through 3/8/17. The record indicates that the patients medical history includes hypertension and skin basal/squamous cancer. His medications included Lisinopril, fish oil, and chondroitin glucosamine. The patient has requested reimbursement for an intermittent limb compression device rental (E0676) provided from 2/22/17 through 3/8/17. The Health Insurer has denied this request as not medically necessary. The medical literature recommend identifying subjects who are at a high risk of developing venous thrombosis and providing prophylactic measures such as consideration for anticoagulation therapy. Jobin and colleagues state that patients with moderate to high risk of venous thromboembolism should have pharmacologic prophylaxis, unless contraindicated. If pharmacologic therapy is contraindicated, then mechanical prophylaxis with intermittent pneumatic compression is recommended. In this case, the patients medical history was positive for hypertension. He underwent right knee arthroscopic debridement and lateral release on 2/22/17. An intermittent pneumatic compression device was ordered for post-operative use to reduce pain, swelling, and edema, mitigate the risk of DVT, and improve his range of motion and strength. The patients risk factors were documented to include the patients age, length of surgery, arthroscopic surgery, and restricted mobility. However, there is no documentation that anticoagulation therapy would be contraindicated, or standard compression stockings were insufficient, to warrant the use of mechanical prophylaxis following arthroscopic knee surgery. The medical records submitted for review fail to support the medical necessity of the device at issue in this case. Therefore, based on evidence-based literature, the intermittent limb compression device rental provided from 2/22/17 through 3/8/17 was not medically necessary for treatment of the patients medical condition. Therefore, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.