Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 46-year-old female who was diagnosed with chronic ACL deficiency, right knee with meniscal pathology in August 2004. She is status post knee arthroscopy with ACL reconstruction, extensive lateral meniscectomy, patellofemoral chondroplasty, and lateral femoral chondroplasty. Her physician has recommended she use a continuous passive motion (CPM) machine for four months following surgery. She is requesting reimbursement for use of the CPM machine. The Health Plan has denied this request indicating CPM therapy is investigational for treatment of the patients condition.There is insufficient evidence supporting the use of a CPM machine in this case. There is no class I data demonstrating superior ACL outcomes with use of a CPM machine as opposed to standard rehabilitation modalities. The use of CPM in this case was not standard of care and not medically warranted. Accordingly, I have determined the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:The patient is a 46-year-old woman who underwent ACL reconstruction. Postoperatively, a continuous passive motion (CPM) machine was used for a prolonged period of time. The patient is requesting reimbursement for the CPM machine from her Health Plan. The Health Plan indicates the efficacy of CPM therapy for patients such as this patient has not been established in peer-reviewed scientific literature. Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. If a surgeon feels the device would be beneficial in a particular case, it should be authorized. Numerous studies have shown benefit with CPM. However, there is no evidence prolonged CPM therapy (in excess of four weeks) is likely to result in an improved outcome. Accordingly, I have determined a CPM machine was medically reasonable and likely to be more beneficial than any available standard therapy for the patients successful postoperative rehabilitation for four weeks following surgery. The Health Plans denial should be partially overturned.Physician 3: The patient is a 46-year-old female who apparently sustained a major soft tissue injury to her right knee during adolescence. This injury was treated non-operatively. As a result of this injury she developed chronic anterior cruciate ligament insufficiency that led to post-traumatic grade III chondromalacia of the patellofemoral and tibiofemoral joints as well as a complex degenerative tear of the lateral meniscus. On 8/19/04, the patient underwent an arthroscopy of her right knee with chondroplasty of the patellofemoral joint and lateral femoral condyle as well as a partial lateral meniscectomy. At the same time, an arthroscopically assisted anterior cruciate ligament reconstruction was performed utilizing a bone-patellar tendon-bone autograft. Her postoperative care included immediate continuous passive motion (CPM) therapy. The CPM unit was continued in the home setting for up to four months from the patients surgery. The Health Plan has denied coverage for the CPM unit indicating that its use after any knee procedure other than total knee arthroplasty is investigational and no more beneficial than standard postoperative therapies.Continuous passive motion (CPM) in the immediate postoperative period has been shown to be an effective adjunct to physical therapy in patients after total knee arthroplasty. No studies have documented, however, that it is more beneficial than standard treatments to restore knee motion after other types of surgery such as ACL reconstruction. Review of the relevant scientific literature did not identify any peer-reviewed literature demonstrating the superiority of CPM therapy over standard therapies after ACL reconstruction. Its use in this setting is not standard of care and of no proven advantage over standard postoperative therapies. Accordingly, I have determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.