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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for cooling or combined cooling/heating device (with or without pneumatic compression) for treatment of the enrollee who underwent right knee surgery. Findings: Two of the three physician reviewers found that patient was diagnosed with a right lateral meniscus bucket handle tear. He had intermittent right knee locking for several years that had recently worsened. Imaging demonstrated a displaced (bucket-handle) tear of the meniscus. The most recent episode caused the knee to lock up for several days. He underwent right arthroscopic lateral meniscus repair. The patient underwent right knee arthroscopy for a right lateral meniscus tear. He used a water circulation cold pad with pump after surgery. The Health Plan denied reimbursement indicating that the cooling or combined cooling/heating device (with or without pneumatic compression) was investigational for the treatment of this patients medical condition. Overall, there is a lack of large volume long-term studies supporting significant outcome differences with regards to continuous flow cryotherapy versus standard cold packs in this clinical setting. Evidence based medical guidelines and peer-reviewed literature generally support consideration of cryotherapy with a water circulating cold pad with pump in the postoperative period following complex knee arthroscopic surgery. However, the literature indicates that this treatment modality is primarily from a convenience standpoint. One study conducted a prospective randomized study of 53 patients comparing postoperative pain control with use of a continuous flow cryotherapy system versus standard ice therapy following outpatient knee arthroscopy. In another study, they concluded that the limited evidence available is insufficient to draw definitive conclusions on the effectiveness of cryotherapy for outcomes other than reduction in pain 48 hours after surgery. They noted that there is a need for well-designed, good quality randomized trials to answer other questions related to this intervention and increase the precision of future systematic reviews. Another study found that patients using a temperature controlled continuous cold flow device showed significantly better results the first postoperative day. In this study as well, they reported that further studies with higher number of patients and longer follow-up are required before assessing the beneficial effects on rehabilitation. In light of the lack of high quality evidence showing the superior efficacy of the device at issue, the cooling or combined cooling/heating device (with or without pneumatic compression) was not likely to have been more effective than standard cold packs for the treatment of this patients medical condition. Final Result: The reviewers determined that the I have determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts 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.