Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the right knee. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees patellar contusion. A review of the record indicates that the enrollee has been diagnosed with acute patellar contusion, right knee. The enrollee was seen on 10/9/18, after slipping and falling directly on the right knee. The provider reported the enrollee previously had an arthroscopy with trimming of a discoid lateral meniscus of the right knee a year ago with good result. The enrollee was seen on 10/23/18, with reported worsening of right knee pain. The provider is recommending MRI of the right knee. The American College of Radiology ACR Appropriateness Criteria recommend MRI for adults or children with a history of fall with no fracture seen on x-ray, and suspicion of internal derangement. MRI is considered the optimal imaging modality for identifying meniscal, ligament, chondral and non-displaced bone injuries about the knee. Numerous studies have shown that MRI has a high diagnostic accuracy in identifying traumatic intra-articular knee lesions. Bateni and colleagues concluded that MRI is especially useful in the pediatric population because of its lack of ionizing radiation and superb assessment of the physis, apophysis, and adjacent soft tissues. MRI may better depict acute or chronic physical injury, confirm acute or repetitive apophyseal injury, indicate an unstable osteochondral defect, demonstrate a labral tear, or reaffirm patellofemoral syndrome. Nationally recognized evidence based medical guidelines recommend MRI for the knee in the setting of acute trauma, including significant trauma (e.g., motor vehicle accident), or if suspecting posterior knee dislocation or ligament or cartilage disruption. This patient presents with persistent right knee pain, swelling, and stiffness following a slip and fall injury in early October, directly affecting her right knee. Significant functional limitations are noted in activities of daily living. Past surgical history is positive for right knee lateral meniscal surgery in 2017. Clinical examination findings have documented effusion, limited range of motion, moderate medial and lateral patellar facet tenderness, and slight lateral joint line tenderness. X-rays have been obtained and reported to be normal. She has reported worsening symptoms despite conservative treatment including ice, elevation, rest, activity modification, and non-steroidal anti-inflammatory drugs (NSAIDs). The treating physician did not want to order physical therapy due to her increased pain and swelling. The differential diagnosis is patellar contusion versus osteochondral fracture. Evidence based medical guidelines and literature supports MRI in this patients clinical setting. Therefore, this request for right knee MRI is medically necessary. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.